Medicare AdvantageCoverageMedium impact
MA08.063h, Pertuzumab (Perjeta®)
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated MA08.063h to MA08.063i effective 12/29/2025, aligning pertuzumab (Perjeta®) and pertuzumab-dpzb (Poherdy) coverage criteria with current FDA labeling and NCCN guidelines. Policy criteria were revised for breast cancer, colon cancer, biliary, and rectal cancer treatment; all ICD-10 diagnosis codes were removed from the policy document, requiring billing teams to report the most appropriate diagnosis code based on medically necessary criteria.
Action Required
By 12/29/2025: Billing team must transition from MA08.063h to MA08.063i in billing systems and prior authorization workflows. Remove any hard-coded ICD-10 diagnosis codes from billing templates and encounter forms, as Attachment A (ICD-10 code list) has been removed; instead, require providers to report the most appropriate diagnosis code that supports medical necessity per the updated policy criteria. Update prior authorization protocols to reflect revised coverage criteria for breast cancer (early stage, inflammatory), colon cancer, biliary, and rectal cancer treatments. Verify that claims processing system references MA08.063i (not superseded MA08.063h). Educate oncology/hematology providers on the new coding requirements. Claims submitted under outdated MA08.063h guidance after the effective date may be denied.