Download Ibrance

MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – IBRANCE™
(May 2016)
Drug
Therapeutic Area
Ibrance™ (palbociclib capsules) [Pfizer]
Oncology
Approval criteria
 Patient has a diagnosis of estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative
advanced breast cancer AND
 Ibrance treatment will be in combination with letrozole as initial endocrine based therapy in postmenopausal women OR
 In combination with fulvestrant in women with disease progression following endocrine therapy
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Quantity limit
 21 capsules every 28 days
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Background information
IBRANCE is a kinase inhibitor indicated in combination with letrozole for the treatment of postmenopausal women with estrogen
receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer as initial endocrinebased therapy for their metastatic disease
MHCP Provider Call Center 651-431-2700 or 800-366-5411