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AetnaAll Plans · Coverage · Medical Policy · OncologyMedium impact

Pertuzumab Products (CPB 0973, reviewed 2026-04-27)

Effective date
Not stated in the notice
Identified
Aug 13, 2026

Summary

Aetna's policy covers pertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) for the listed indications, including HER2-positive metastatic breast cancer, neoadjuvant and adjuvant early breast cancer, and HER2-positive colorectal, biliary tract, salivary gland, appendiceal, and small bowel cancers in combination with trastuzumab under the stated criteria. Precertification of both products is required of all Aetna participating providers and members in applicable plan designs, and adjuvant and neoadjuvant breast cancer treatment is approved for a total of 12 months of therapy. Gastric, lung, ovarian, pancreatic, prostate, and uterine cancers are considered experimental, investigational, or unproven.

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What to do

Action · 8 steps
01Billing team: Confirm precertification for pertuzumab in applicable plan designs.
02For Perjeta, call (866) 752-7021 or fax (888) 267-3277, and see Specialty Pharmacy Precertification for Statement of Medical Necessity forms.
03Billing team: For commercial plans, check the Aetna Commercial Clinical Program Summary, because a trial of a lower-cost preferred drug may be required before a higher-cost drug in the same class is approved.
04Billing team: Bill J9306 (injection, pertuzumab, 1 mg) and confirm the claim matches an indication listed in the criteria for initial approval, including HER2-positive status for C50.011 through C50.A2.
05Billing team: For reauthorization, continuation is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
06Billing team: Adjuvant and neoadjuvant breast cancer therapy is approved for a total of 12 months.
07Billing team: The Site of Care Utilization Management Policy applies to pertuzumab, so check the site of service before billing infusion services.
08For Medicare criteria, use the Medicare Part B Criteria.

Codes mentioned

J93069641396417C50.011C50.A2

Original notice

Pertuzumab Products (CPB 0973, reviewed 2026-04-27)
aetna.com · Always check the source before changing claims.
View original ↗

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Related policy hubs

Aetna policiesOncologyCode J9306Code 96413Code 96417Code C50.011Code C50.A2

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