Ibrance — Blue Cross Blue Shield of Kansas

Initial criteria

• Target Agent(s) will be approved when ALL of the following are met:
• 1. ONE of the following: (A) patient has been treated with the requested agent within the past 180 days OR (B) prescriber states patient is being treated with the requested agent within past 180 days and is at risk if therapy is changed OR (C) ALL of the following: (1) patient has an FDA labeled or compendia-supported indication; (2) patient age within FDA labeling or supported; (3) required genetic/diagnostic testing completed if applicable; (4) use as monotherapy or combination therapy supported; (5) appropriate line of therapy or prerequisite agents tried/intolerant/contraindicated.
• 2. Requested agent is preferred agent OR if non-preferred, one preferred agent has been tried, intolerant, contraindicated, or NCCN prefers non-preferred agent.
• 3. The patient does not have any FDA labeled contraindications to the requested agent.
• 4. Requested dose within FDA labeling or compendia support.