Pharmacy Prior Authorization Criteria

Verzenio (abemaciclib)

For diagnosis of Advanced or Metastatic Breast Cancer
Indicated in combination with fulvestrant for the treatment of adult patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer with disease progression following endocrine therapy.
For diagnosis of Advanced or Metastatic Breast Cancer
Indicated as monotherapy for the treatment of adult patients with HR-positive, HER2-negative advanced or metastatic breast cancer with disease progression following endocrine therapy and prior chemotherapy in the metastatic setting.
For diagnosis of Advanced or Metastatic Breast Cancer
Indicated in combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment of adult patients with HR-positive, HER2-negative advanced or metastatic breast cancer.
For diagnosis of Early Breast Cancer
Indicated in combination with endocrine therapy (tamoxifen or an aromatase inhibitor) for the adjuvant treatment of adult patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, node-positive, early breast cancer at high risk of recurrence.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Breast Cancer

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Breast Cancer

2024-07-03, 2024-05-20, 2023-06-22, 2023-06-08, 2023-04-26, 2022-05-06, 2021-11-30, 2021-04-12, 2020-04-07

2024-07-03: Added EHB formulary to guideline. No changes to criteria.
2024-05-20: 2024 UM Annual Review. No criteria changes
2023-06-22: Removed Oncology specialist requirement
2023-06-08: Program update to consolidate under one umbrella Breast Cancer criterion. Removed any criteria related disease classification or combination therapy.
2023-04-26: 2023 UM Annual Review. Updated criteria based on full FDA labeling for expended indications. Updated references
2022-05-06: 2022 Annual Review- Updated criteria to include men in the HR+, HER2-negative advanced/metastatic setting when used in combination with an aromatase inhibitor
2021-11-30: Updated criteria for new indication
2021-04-12: Annual Review: updated background
2020-04-07: Annual Review; updated references & background