CommercialCoverageMedium impact
08.01.07k, Pertuzumab (Perjeta®)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.01.07k to version 08.01.07l, effective 12/29/2025. Coverage criteria for pertuzumab (Perjeta®) and biosimilar pertuzumab-dpzb (Poherdy) were updated to align with FDA labeling and NCCN compendia for breast cancer, colon cancer, biliary and rectal cancers. All ICD-10 diagnosis codes were removed from the policy; billing teams must now report the most appropriate diagnosis code based on medical necessity criteria without relying on a policy-provided code list.
Action Required
By December 29, 2025: Billing team must update systems to reflect policy version 08.01.07l and remove references to attachment A (ICD-10 codes). Providers and billing staff must ensure claims for pertuzumab (J9306) and pertuzumab-dpzb (C9399, J3590) include the most appropriate diagnosis code that directly supports medical necessity criteria outlined in the updated policy (HER2-positive breast cancer indications, and expanded criteria for colon, biliary, and rectal cancers). Verify HER2 testing documentation (IHC 3+, FISH >2.0, or approved ISH results) is present before claim submission. Update prior authorization request templates to reference policy version 08.01.07l instead of 08.01.07k. Failure to report appropriate diagnosis codes or submit HER2 verification may result in claim denials.