requested agent (requiring trial of imatinib) — Blue Cross Blue Shield of Illinois

Preferred products

• imatinib tablets

Initial criteria

• The prescriber has stated or submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer or an associated condition related to stage four advanced metastatic cancer [chart notes required]
• The use of the requested agent is consistent with best practices for treatment of stage four advanced metastatic cancer or an associated condition; supported by peer-reviewed, evidence-based literature; and FDA approved
• OR the patient is currently being treated with the requested agent and is stable on it [chart notes required]
• OR the patient has tried and had an inadequate response to imatinib tablets [chart notes required]
• OR imatinib tablets were discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]
• OR the patient has intolerance or hypersensitivity to imatinib tablets not expected to occur with the requested agent [chart notes required]
• OR the patient has an FDA labeled contraindication to imatinib tablets not expected with the requested agent [chart notes required]
• OR imatinib tablets are expected to be ineffective or cause significant barriers, worsen comorbid condition, decrease function, or cause harm [chart notes required]
• OR imatinib tablets are not in the best interest of the patient based on medical necessity [chart notes required]
• OR the patient has tried another drug in same class or with same mechanism and discontinued for lack of efficacy or adverse event [chart notes required]
• OR support exists for use of requested agent over imatinib (e.g., swallowing difficulties)

Approval duration

12 months