Kisqali (ribociclib) — CareFirst (Caremark)

recurrent or metastatic endometrial carcinoma with ER-positive tumors

Initial criteria

For breast cancer: member has HR-positive, HER2-negative recurrent or metastatic disease AND Kisqali will be used in combination with an aromatase inhibitor or fulvestrant
For adjuvant treatment: member has HR-positive, HER2-negative early-stage breast cancer at high risk of recurrence (e.g., any lymph node involvement excluding microscopic nodal involvement OR no nodal involvement and tumor size >5 cm OR tumor size 2 to 5 cm and Grade 2 with high genomic risk or Ki-67 ≥ 20% OR Grade 3) AND Kisqali will be used in combination with an aromatase inhibitor
For endometrial carcinoma: member has recurrent or metastatic endometrial carcinoma with ER-positive tumors AND Kisqali will be used in combination with letrozole
Required documentation: laboratory results confirming HR and HER2 status for breast cancer or ER status for endometrial carcinoma

For early-stage HR-positive, HER2-negative breast cancer at high risk of recurrence: approval may continue for up to 3 years total or until disease recurrence or unacceptable toxicity while on the current regimen
For recurrent or metastatic breast cancer or endometrial carcinoma: approval may continue if no evidence of unacceptable toxicity or disease progression while on current regimen

12 months