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.
Food and Drug Administration (FDA) Indications
Ixabepilone (Ixempra) may be considered medically necessary when ANY ONE of the following criteria is met:
- Breast cancer, locally advanced or metastatic, as monotherapy in individuals whose tumors are resistant or refractory to anthracyclines, taxanes, and capecitabine; or
- Breast cancer, locally advanced or metastatic, in combination with capecitabine in individuals who are taxane- or anthracycline-resistant, or taxane-resistant with a contraindication to anthracyclines.
Ixabepilone (Ixempra) is considered experimental/investigational forall other indications and therefore, non-covered. Scientific evidence does notsupport the use for any other indications than those listed above.
Procedure Codes