Kisqali Femara Co-Pack — CareFirst (Caremark)

HR-positive, HER2-negative recurrent or metastatic breast cancer

Initial criteria

For breast cancer, member has HR-positive, HER2-negative disease
For adjuvant treatment of early-stage breast cancer, member has HR-positive, HER2-negative disease at high risk of recurrence (defined as any lymph node involvement excluding microscopic nodal involvement, or no nodal involvement and tumor size greater than 5 cm, or tumor size 2 to 5 cm and Grade 2 with high genomic risk or Ki-67 ≥ 20% or Grade 3)
For endometrial carcinoma, member has recurrent or metastatic disease with ER-positive tumors
Documentation of HR and HER2 status for breast cancer or ER status for endometrial carcinoma is provided

For early-stage HR-positive, HER2-negative breast cancer, authorization may continue until completion of 3 years of treatment or until disease recurrence or unacceptable toxicity while on the current regimen
For recurrent or metastatic breast cancer or endometrial carcinoma, continue if there is no evidence of unacceptable toxicity or disease progression while on the current regimen

12 months