Ado-trastuzumab emtansine (Kadcyla®)

OFFICE ADMINISTERED

Indications for Prior Authorization:

HER2 positive, metastatic breast cancer

All of the following must be met as a condition for coverage:

Must have previous treatment with Herceptin® and taxane (separately or in combination)

This Medication is Not Approvable for the following condition(s):

Any condition not listed above as an approved indication.

Dosing:

Recommended dose: 3.6mg/kg IV every 3 weeks (21 day cycle) until disease progression or unacceptable toxicity

Duration of Therapy:

Initial authorization: one year


 

Last review date: December 3, 2013

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