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​Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®) coverage criteria changes

December 22, 2021

​Effective March 21, 2022, Independence will update the coverage criteria for Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®). The changes include the addition of left ventricular ejection fraction result requirements prior to the initiation of the drug.

  • Left ventricular ejection fraction (LVEF) greater than 55 percent for early-stage breast cancer
  • Left ventricular ejection fraction (LVEF) greater than 50 percent for later-stage breast cancer

These changes align with the U.S. Food and Drug Administration label dosing guidelines.

Commercial and Medicare Advantage Policy Notifications were posted December 21, 2021:

  • #08.01.72a: Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)
  • #MA08.129a: Pertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)

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