Zytiga 500 mg — 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 agent is being used to treat the cancer or an associated condition [chart notes required]
AND the use of the requested 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 agent [chart notes required]
OR the patient has tried and had an inadequate response to generic abiraterone 250 mg tablets [chart notes required]
OR generic abiraterone 250 mg tablets discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]
OR intolerance or hypersensitivity to generic abiraterone 250 mg tablets not expected with requested agent [chart notes required]
OR FDA labeled contraindication to generic abiraterone 250 mg tablets not expected with requested agent [chart notes required]
OR generic abiraterone 250 mg tablets expected to be ineffective or cause significant barrier, worsen comorbid condition, decrease function, or cause harm [chart notes required]
OR generic abiraterone 250 mg tablets 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 requested agent over generic abiraterone 250 mg tablets

12 months