Ogivri will be added to medical benefit coverage on August 1, instead of Ontruzant.

In May, we communicated that Ontruzant® would be added to medical benefit coverage effective August 1. Merck, the maker of Ontruzant, now plans to remove providers’ purchasing discounts for this drug beginning in quarter 3 of 2024.

To help our members get the care they need with options that are affordable for providers, we’ll no longer be adding Ontruzant to coverage under the medical benefit for commercial group and individual members. For Medicare Advantage members, we'll no longer be removing prior authorization requirements.

Instead, effective August 1, Ogivri® will be added to coverage under the medical benefit with no prior authorization requirements for commercial group and individual members, and we’ll remove prior authorization requirements for Ogivri for our Medicare Advantage members.

What do these drugs treat?

Ogivri and Ontruzant are both biosimilars for Herceptin® and are used to treat breast cancer, gastric cancer and esophagogastric cancer.

How will this impact you?

Ogivri:

• For our commercial group, individual and Medicare Advantage members, Ogivri will be covered under the medical benefit with no prior authorization requirements effective August 1.

Ontruzant:

• For commercial group and individual members, Ontruzant will remain a non-covered drug. If you’d like to seek treatment with Ontruzant for your patients, prior authorization is required.
• For Medicare Advantage members, Ontruzant will remain a covered drug with prior authorization requirements, which include trials of both Ogivri and Trazimera.

As a reminder, Kanjinti will no longer be covered under the medical benefit effective August 1 for our commercial group and individual members. If you’d like to seek treatment with Kanjinti for your patients, prior authorization is required. For Medicare Advantage members, Kanjinti will remain covered with prior authorization requirements, including trials of both Ogivri and Trazimera. Note: This only impacts members who haven’t previously been administered Kanjinti. Commercial group, individual and Medicare Advantage members currently receiving treatment with Kanjinti will remain covered.

Trazimera will continue to be a covered treatment option with no prior authorization requirements for commercial group, individual and Medicare Advantage members.

Have questions?

Call us toll-free at: 800.466.6642 We’re available 8 a.m. to 7 p.m., Monday – Friday and from 8:30 a.m. to 12 p.m. on Saturday.