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


Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: May 2013 | Reviewed: December 3, 2013