Medicare AdvantageBilling CodesHigh impact
MA08.063i, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Jul 27, 2026
We identified it
Jul 28, 2026
Summary
Independence Blue Cross updated Medicare Advantage policy MA08.063i to add coverage for Poherdy (pertuzumab-dpzb), a new FDA-approved biosimilar to Perjeta. The policy title was changed to reflect both drugs, and two new HCPCS codes (C9399 and J3590) were added to represent Poherdy. Coverage criteria for pertuzumab were expanded to align with FDA labeling and NCCN guidelines for breast cancer, CNS, colon cancer, appendiceal adenocarcinoma, biliary, and rectal cancers.
Action Required
By July 27, 2026: Billing team must update billing system to recognize and process HCPCS codes C9399 and J3590 as valid representations of Poherdy (pertuzumab-dpzb) for Medicare Advantage claims. Ensure existing J9306 code continues to process for Perjeta (pertuzumab). Update internal billing guidelines and provider communication materials to clarify that both the brand drug (Perjeta, J9306) and biosimilar (Poherdy, C9399/J3590) are now covered under the same medical necessity criteria. Verify that prior authorization systems reflect updated coverage criteria for breast cancer, CNS, colon cancer, appendiceal adenocarcinoma, biliary, and rectal cancers. Train billing staff on the distinction between the two drugs and confirm HER2 testing documentation requirements are in place before processing claims. Claims submitted with C9399 or J3590 without proper HER2 verification or medical necessity documentation will be denied.