Ibrance (palbociclib capsules and tablets) — Cigna

Breast Cancer in a Woman

Initial criteria

Patient is age ≥ 18 years
Patient has recurrent or metastatic disease
Patient has hormone receptor positive (HR+) [i.e., estrogen receptor positive (ER+) and/or progesterone receptor positive (PR+)] disease
Patient has human epidermal growth factor receptor 2 (HER2)-negative breast cancer
Patient meets ONE of the following (i or ii): i. Patient is postmenopausal; OR ii. Patient is pre/perimenopausal and meets ONE of the following (a or b): a) Patient is receiving ovarian suppression/ablation with a gonadotropin-releasing hormone (GnRH) agonist; OR b) Patient has had surgical bilateral oophorectomy or ovarian irradiation
Patient meets ONE of the following (i or ii): i. Ibrance will be used in combination with anastrozole, exemestane, or letrozole; OR ii. Ibrance will be used in combination with fulvestrant

1 year