Afinitor — Blue Cross Blue Shield of Montana

stage four advanced metastatic cancer or 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]
The use of the requested agent is consistent with best practices for treatment of stage four advanced, metastatic cancer or associated condition; supported by peer-reviewed, evidence-based literature; and approved by the FDA
OR patient currently treated and stable on requested agent [chart notes required]
OR patient has tried and had inadequate response to the generic equivalent [chart notes required]
OR generic equivalent discontinued due to lack of efficacy, effectiveness, or adverse event [chart notes required]
OR patient has intolerance, hypersensitivity, or labeled contraindication to generic equivalent not expected with brand agent [chart notes required]
OR generic equivalent expected ineffective or causes adherence/comorbidity/functional/adverse issues [chart notes required]
OR generic equivalent not in best interest of patient based on medical necessity [chart notes required]
OR patient has tried another drug in same class/mechanism as generic equivalent discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]
OR support for use of requested brand agent over generic equivalent
AND patient does not have any FDA labeled contraindications to the requested agent

12 months