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Herceptin (trastuzumab) Prior Authorization of Benefits (PAB) Form

Herceptin (trastuzumab) Prior Authorization of Benefits (PAB) Form 2025

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The document is a Prior Authorization of Benefits (PAB) form for Herceptin (trastuzumab), used in the treatment of breast cancer and certain types of gastric and esophageal adenocarcinoma. It requires detailed patient and physician information, medication specifics, diagnosis, and approval criteria to be filled out completely before submission to the Prior Authorization of Benefits Center. The form emphasizes the importance of accurate information for authorization and includes confidentiality notices regarding patient data.

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What is the difference between trastuzumab and ?

is indicated in adults: In combination with paclitaxel for the first line treatment of HER2-overexpressing metastatic cancer. As a single agent for treatment of HER2-overexpressing cancer in patients who have received one or more chemotherapy regimens for metastatic disease.

Who is eligible for ?

(trastuzumab) is a Medicare covered drug approved for the treatment of certain Human Epidermal growth factor Receptor 2-positive (HER2+) cancers.

Does insurance cover ?

With the Genentech Oncology Co-pay Assistance Program, eligible patients with commercial insurance could pay as little as $0 per treatment for . Co-pay assistance of up to $25,000 is provided per calendar year.

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