Subject: Specialty Quantity Limit Ibrance 1904-H P2026

Drug

IBRANCE  (palbociclib)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Ibrance (palbociclib) 75 mg tablets	21 tablets per 28 days
Ibrance (palbociclib) 100 mg tablets	21 tablets per 28 days
Ibrance (palbociclib) 125 mg tablets	21 tablets per 28 days
Ibrance (palbociclib) 75 mg capsules	21 capsules per 28 days
Ibrance (palbociclib) 100 mg capsules	21 capsules per 28 days
Ibrance (palbociclib) 125 mg capsules	21 capsules per 28 days

FDA-Recommended Dosing

Breast Cancer:

·        Starting dose: 125 mg once daily for 21 consecutive days followed by 7 days off treatment to comprise a complete cycle of 28 days.

·        First dose reduction: 100 mg once daily for 21 consecutive days followed by 7 days off treatment to comprise a complete cycle of 28 days.

·        Second dose reduction: 75 mg once daily for 21 consecutive days followed by 7 days off treatment to comprise a complete cycle of 28 days.

Dose modifications may be required for adverse reactions, severe hepatic impairment, or use with strong CYP3A4 inhibitors.

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Ibrance capsules [package insert]. New York, NY: Pfizer Inc.; September 2025.

2.     Ibrance tablets [package insert]. New York, NY: Pfizer Inc.; September 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 14, 2026