CurrentCignaPolicy N/A

Oncology - Verzenio Prior Authorization Policy

Cigna prior authorization policy for Verzenio (abemaciclib tablets) defining medical necessity criteria, approval durations, covered FDA indications (early breast cancer adjuvant; recurrent/metastatic breast cancer in women and men; recurrent/metastatic endometrial cancer with letrozole) and that other uses are considered experimental/investigational.

Policy Summary

PayerCigna

PolicyOncology - Verzenio Prior Authorization Policy

Policy CodePolicy N/A

Change TypeAnnual revision — no criteria changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age, HR+/HER2 status, node/high-risk criteria, prior endocrine/chemotherapy history, menopausal/GnRH or oophorectomy status, and prior anti-HER2 regimens as applicable.

POLICY UPDATE CHANGES

Annual Revision noted: 'No criteria changes.' for the 02/26/2025 review.

4Covered Indications (listed)

1Approval durations (distinct)

1Not covered category (catch-all)

Coverage Summary

Cigna prior authorization policy for Verzenio (abemaciclib tablets) defining medical necessity criteria and approval durations. Covered indications include: Early (adjuvant) breast cancer (node-positive, high-risk) with approval duration of 2 years (total); Recurrent/metastatic breast cancer in women and men with approval duration of 1 year; and Recurrent/metastatic endometrial cancer for ER-positive tumors in combination with letrozole with approval duration of 1 year. Uses not specified in the FDA-approved indications or supported by the policy are considered experimental, investigational or unproven.

Initial Therapy Criteria (by indication)

Breast Cancer - Early (adjuvant)

Approve for 2 years (total) if ALL of the following are met:

Endometrial Cancer (recurrent or metastatic)

Approve for 1 year if ALL of the following are met:

Continuation / Recurrent or Metastatic Therapy Criteria

Breast Cancer - Recurrent or Metastatic (Women)

Approve for 1 year if ALL of the following are met:

Breast Cancer - Recurrent or Metastatic (Men)

Approve for 1 year if ALL of the following are met:

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is recommended/required for Verzenio prescriptions; approvals are granted for the durations specified by indication (2 years for early breast cancer; 1 year for recurrent/metastatic breast or endometrial cancer).

Early (adjuvant) breast cancer: 2 years (total)
Recurrent or metastatic breast cancer (women and men): 1 year
Recurrent or metastatic endometrial cancer (with letrozole): 1 year

Documentation Required

Clinical documentation to support indication

Provider must document age, HR+ status, HER2 status, node status/high-risk criteria (for adjuvant), prior endocrine therapies and prior chemotherapy (where applicable), menopausal status and use of GnRH agonist or surgical oophorectomy when required, and prior anti-HER2 regimens when applicable.

Age (≥ 18 years)
Hormone receptor positive (HR+) status (ER+ and/or PR+)
HER2 status
Node status / high-risk criteria for adjuvant (≥4 positive nodes, or 1–3 nodes with grade 3 disease or tumor size ≥5 cm)
Prior endocrine therapies
Prior chemotherapy (where applicable, e.g., metastatic monotherapy eligibility)
Menopausal status and use of GnRH agonist or surgical bilateral oophorectomy when required
Prior anti-HER2 regimens when applicable (e.g., ≥3 prior anti-HER2 regimens for HER2+ metastatic pathway)

Clinical Evidence & References

Verzenio (abemaciclib) is a cyclin-dependent kinase (CDK4/6) inhibitor indicated for hormone receptor–positive (HR+), HER2‑negative breast cancer in both the adjuvant (early) and advanced/metastatic settings. NCCN guidelines (Breast Cancer v1.2025) recommend Verzenio with an aromatase inhibitor (category 2A) or fulvestrant (category 1) as a preferred first-line regimen for recurrent or stage IV HR+, HER2‑negative disease and recommend Verzenio for 2 years as adjuvant therapy in high‑risk node‑positive patients. NCCN Uterine Neoplasms (v2.2025) recommends Verzenio in combination with letrozole for ER‑positive recurrent/metastatic endometrial carcinoma (category 2A).

Source prescribing information: Verzenio tablets prescribing information, Eli Lilly; November 2024

Guidelines referenced: NCCN Breast Cancer v1.2025 and NCCN Uterine Neoplasms v2.2025

Background

Verzenio is a CDK4/6 inhibitor indicated for HR+, HER2‑negative breast cancer in adults for adjuvant treatment of node‑positive, high‑risk early breast cancer (in combination with endocrine therapy) and for advanced/metastatic disease (in combination with an AI or fulvestrant, or as monotherapy after progression and prior chemotherapy). NCCN guidelines discuss Verzenio and include recommendations for its use in these settings.

Definitions:

woman* / man*: Defined as individuals with the biological traits of a woman or man, respectively, regardless of gender identity or gender expression.

GnRH agonist / analog: Examples include leuprolide acetate, Lupron Depot, Trelstar (triptorelin), Zoladex (goserelin); analogs include Firmagon (degarelix), Orgovyx (relugolix).

Revision History

02/26/2025reviewLatest

Annual Revision noted: "No criteria changes."

02/22/2023administrative_update

Administrative update recorded in 2023 (overview and indication wording changes).

02/21/2024administrative_update

Administrative update recorded in 2024 (edits to approval durations and addition of HER2-positive pathways).

Policy Summary

PayerCigna

PolicyOncology - Verzenio Prior Authorization Policy

Policy CodePolicy N/A

Change TypeAnnual revision — no criteria changes

Effective Date

Next Review Date

On This Page

OpenPayer

Oncology - Verzenio Prior Authorization Policy

Coverage Summary

Initial Therapy Criteria (by indication)

Continuation / Recurrent or Metastatic Therapy Criteria

Unproven / Not Covered

Applicable Codes

Provider Actions & Documentation Requirements

Clinical Evidence & References

Background

Revision History