palbociclib — CareFirst (Caremark)

Initial criteria

• Diagnosis of HR-positive, HER2-negative recurrent, advanced, or metastatic breast cancer AND the requested medication is used in combination with an aromatase inhibitor (e.g., anastrozole, exemestane, letrozole) OR fulvestrant
• OR diagnosis of endocrine-resistant, PIK3CA-mutated, HR-positive, HER2-negative locally advanced, recurrent, or metastatic breast cancer AND used in combination with inavolisib and fulvestrant
• OR diagnosis of unresectable retroperitoneal well-differentiated/dedifferentiated liposarcoma AND used as a single agent
• Documentation of HR and HER2 status, and PIK3CA mutation testing where applicable

Reauthorization criteria

• Member is continuing treatment for an indication previously approved and there is no evidence of unacceptable toxicity or disease progression while on the current regimen

Approval duration

12 months