HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)

OFFICE ADMINISTRATION

Indications for Prior Authorization:
  • Indicated for adjuvant treatment of adults with HER2 overexpressing node positive or node negative breast cancer:
    • As part of a treatment regimen consisting of doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel
    • As part of a treatment regimen with docetaxel and carboplatin
    • As a single agent following multi-modality anthracycline based therapy
Patients must meet the following criteria for the indication(s) above:
  • Patient is 18 years of age or older, AND
  • Medication is prescribed by or in consultation with an oncologist, AND
  • Patient has a diagnosis of HER2 positive breast cancer as supported by chart note documentation, AND
  • Patient meets one of the following:
    • Herceptin Hylecta™ is to be used for adjuvant treatment, OR
    • Herceptin Hylecta™ is used for metastatic disease
Dosing:
  •  600 mg/10,000 units (600 mg trastuzumab and 10,000 units
    hyaluronidase) administered subcutaneously over approximately 2-5 minutes once every three weeks
Approval:
  • 1 year

Last review date: May 21, 2019

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