Afinitor — Blue Cross Blue Shield of Illinois

stage four advanced, metastatic cancer or an associated condition

Preferred products

The prescriber has stated or submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested brand agent is used to treat the cancer or associated condition [chart notes required]
AND the use of the requested brand agent is consistent with best practices, supported by evidence-based literature, and FDA approved
OR the patient is currently treated and stable on the requested brand agent [chart notes required]
OR the patient has tried and had an inadequate response to the generic equivalent [chart notes required]
OR the generic equivalent was discontinued due to lack of efficacy or adverse event [chart notes required]
OR the patient has intolerance or hypersensitivity to the generic equivalent not expected with the brand agent [chart notes required]
OR FDA labeled contraindication to generic equivalent not expected with brand agent [chart notes required]
OR generic equivalent expected ineffective or cause significant barrier, worsen comorbid condition, decrease function, or cause harm [chart notes required]
OR generic equivalent not in best interest of patient [chart notes required]
OR patient has tried another drug in same class/mechanism discontinued due to inefficacy or adverse event [chart notes required]
OR support exists for use of brand agent over generic equivalent
AND patient does not have FDA labeled contraindications to the requested agent

12 months