14 commercial payer policies list Q5117. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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14 policies from 13 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology - ado-trastuzumab emtansine (Kadcyla), pertuzumab (Perjeta), trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera), and trastuzumab and hyaluronidase-oysk (Herceptin Hylecta) – Minnesota Health Care Programs | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Oncology - trastuzumab (Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera), and trastuzumab and hyaluronidase-oysk (Herceptin Hylecta) | Not recorded | Covered with conditions |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Trastuzumab Products (Herceptin, Ontruzant, Herzuma, Ogivri, Trazimera, Kanjinti, Hercessi) | Dec 1, 2016 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Cigna MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Q4 - 2026 JHP MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri), Ado-trastuzumab emtansine (Kadcyla), Trastuzumab-pkrb (Herzuma), Trastuzumab-dttb (Ontruzant), Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta), Trastuzumab-qyyp (Trazimera), Trastuzumab-anns (Kanjinti), Fam-trastuzumab deruxtecan-nxki (Enhertu), Pertuzumab (Perjeta), and Pertuzumab, Trastuzumab, and hyaluronidase-zzxf (Phesgo) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Trastuzumab: Herceptin; Ogivri; Kanjinti; Trazimera; Herzuma; Ontruzant | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5117 |
|---|---|---|
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |