CommercialCoverageHigh impact
Trastuzumab Products (CPB 0313, reviewed 2026-06-08)
Aetna·Oncology, Hematology, Gastroenterology +2 more·Medical Policy
Effective date
Jun 8, 2026
We identified it
Aug 18, 2026
Summary
Aetna updated its Trastuzumab Products medical policy (CPB 0313) effective June 8, 2026, expanding coverage to include multiple cancer types beyond breast cancer (appendiceal, colorectal, esophageal/gastric, biliary tract, salivary gland, small bowel adenocarcinoma, and uterine serous carcinoma) with specific HER2-positive and mutation criteria. All trastuzumab products now require precertification before administration, and billing teams must verify HER2 status, mutation testing results, and appropriate combination therapy requirements for each indication.
Action Required
By June 8, 2026: Billing and prior authorization teams must update Aetna authorization workflows to include the expanded indications beyond breast cancer. (1) Update authorization templates and decision trees to capture and require documentation of: HER2 status (positive/amplified with specific testing method: IHC 3+/ISH+/NGS), RAS and BRAF mutation status (wild-type/negative), and required combination therapy agents (pertuzumab, tucatinib, lapatinib, docetaxel, carboplatin, paclitaxel, neratinib, fulvestrant, or docetaxel per indication). (2) Update precertification request forms to require oncologists to specify cancer type/site and submit molecular testing results. (3) Train prior authorization staff on new approval criteria specific to appendiceal, colorectal, esophageal/gastric, biliary tract, salivary gland, small bowel, and uterine serous carcinoma indications. (4) Implement claim edits to flag trastuzumab claims for non-breast cancer indications that lack documentation of HER2-positive status or required combination therapy. (5) Update denial letters and appeal templates to reflect expanded covered indications. (6) Contact oncology providers in your network to inform them of expanded coverage and new documentation requirements. Failure to obtain precertification or provide required molecular testing documentation will result in claim denials for all trastuzumab products under this policy.