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Ibrance — Medical Mutual

Breast Cancer in Men

Preferred products

  • Verzenio
  • Kisqali
  • Kisqali Femara Co-Pack

Initial criteria

  • Prescribed by or in consultation with a hematologist or oncologist
  • The patient has recurrent, advanced, or metastatic hormone receptor positive (HR+) disease [estrogen receptor positive (ER+) and/or progesterone receptor positive (PR+)]
  • The patient has human epidermal growth factor receptor 2 (HER2)-negative breast cancer
  • The patient is receiving concomitant therapy with a gonadotropin-releasing hormone (GNRH) agonist for suppression of testicular steroidogenesis (e.g., Lupron, Trelstar, Zoladex, Firmagon, Orgovyx)
  • The patient has previously tried one of Kisqali, Kisqali Femara Co-Pack, or Verzenio OR the patient has been taking Ibrance and is continuing therapy [documentation required]
  • Ibrance will be used as first-line endocrine therapy in combination with anastrazole, exemestane, letrozole, or fulvestrant OR Ibrance will be used as second-line or subsequent endocrine therapy in combination with fulvestrant AND a CDK4/6 inhibitor has not been used previously

Approval duration

1 year initial, 1 year reauth