Halaven® (Eribulin) Approval Criteria (Medical Billing Only:
- Diagnosis of metastatic breast cancer; AND
- Previously received at least two chemotherapeutic regimens for the treatment of metastatic disease. Prior therapy should have included an anthracycline and a taxane in either the adjuvant or metastatic setting.
Halaven® (Eribulin) Approval Criteria [Liposarcoma Diagnosis]:
- Diagnosis of unresectable or metastatic liposarcoma; and
- Previously received an anthracycline-containing chemotherapy regimen.
- Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on eribulin therapy.
Prior Authorization Form - Halaven Ibrance® (Palbociclib)* Approval Criteria (Pharmacy Billing Only):
- A diagnosis of advanced metastatic, hormone receptor positive, Human Epidermal Receptor Type 2 (HER2)-negative breast cancer in combination with:
- Letrozole as initial endocrine-based therapy in postmenopausal women; or
- Fulvestrant in women with disease progression following endocrine therapy.
- Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on palbociclib therapy.
Prior Authorization - Ibrance Ixempra® (Ixabepilone) Approval Criteria (Medical Billing Only):
- Diagnosis of metastatic or locally advanced breast cancer; AND
- Usage as either:
- In combination with capecitabine after failure of an anthracycline and a taxane; OR
- May be used in combination in taxane only resistance if anthracyclines not indicated; OR
- Monotherapy after failure of an anthracycline, a taxane, and capecitabine.
Prior Authorization Form - Ixempra Kadcyla® (Ado-Trastuzumab) Approval Criteria (Medical Billing Only):
- Positive expression of Human Epidermal Receptor Type 2 (HER2); AND
- Diagnosis of metastatic breast cancer; AND
- Member has previously received trastuzumab and a taxane, separately or in combination; AND
- Members should also have either:
- Received prior therapy for metastatic disease; OR
- Developed disease recurrence during or within six months of completing adjuvant therapy.
Prior Authorization Form - Kadcyla Perjeta® (Pertuzumab) Approval Criteria (Medical Billing Only):
- Positive expression of Human Epidermal Receptor Type 2 (HER2); AND
- Usage for either:
- Metastatic breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease; OR
- Neoadjuvant treatment of patients with locally advanced, inflammatory, or early stage breast cancer (either greater than 2cm in diameter or node positive); AND
- Used in combination with trastuzumab and docetaxel (neoadjuvant treatment may also contain other agents as well in addition to trastuzumab and docetaxel).
Prior Authorization Form - Perjeta Tykerb® (Lapatinib) Approval Criteria (Pharmacy Billing Only):
- An FDA approved diagnosis of metastatic or recurrent breast cancer; AND
- Positive expression of Human Epidermal Receptor Type 2 (HER2); AND
- Tykerb® must be used in combination with one of the following:
- Herceptin (trastuzumab); OR
- Xeloda (capecitabine); OR
- An aromatase inhibitor [e.g. Aromasin® (exemestane), Femara® (letrozole) or Arimidex® (anastrozole)] if also estrogen receptor positive (ER positive).
Prior Authorization Form - Tykerb |