Ibrance — Medical Mutual

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 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]
• Patient is postmenopausal AND either: 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
• OR Patient is premenopausal or perimenopausal AND receiving ovarian suppression/ablation with a gonadotropin-releasing hormone (GNRH) agonist (e.g., Lupron, Trelstar, Zoladex, surgical bilateral oophorectomy, ovarian radiation) AND either: 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