capivasertib — CareFirst (Caremark)

Initial criteria

• The requested medication will be used in combination with fulvestrant
• Documentation confirms the presence of at least one of the following alterations: PIK3CA, AKT1, or PTEN
• Documentation confirms HR-positive and HER2-negative status
• The member had disease progression while on or after receiving at least one endocrine-based regimen including a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor (e.g., palbociclib [Ibrance], ribociclib [Kisqali], abemaciclib [Verzenio]) in the metastatic setting OR the member had disease recurrence while on or within 12 months of completing adjuvant therapy with an endocrine-based regimen including a CDK4/6 inhibitor

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen

Approval duration

12 months