Medicare AdvantagePrior AuthMedium impact
MA08.063h, Pertuzumab (Perjeta®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage policy MA08.063h for Pertuzumab (Perjeta®) has been updated with changes to medical necessity criteria and medical coding requirements. This affects billing and coverage determination for this cancer medication used primarily in oncology practices.
Action Required
By December 29, 2025: Billing team and oncology providers must review updated medical necessity criteria for Pertuzumab (Perjeta®) claims. Update prior authorization documentation requirements and coding guidelines in billing system. Ensure all future claims meet the new medical necessity criteria to avoid denials.