Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Ixabepilone (Ixempra) may be considered medically necessary for the treatment of metastatic or locally advanced breast cancer when ANY of the following criteria is met:
- As monotherapy in individuals after failure of an anthracycline, a taxane, and capecitabine; or
- In combination with capecitabine in individuals resistant to treatment with an anthracycline and a taxane, or whose cancer is taxane resistant and for whom further anthracycline therapy is contraindicated; or
Compendia Sources
Ixabepilone (Ixempra) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of ixabepilone (Ixempra) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
