Imbruvica tablets — Blue Cross Blue Shield of Montana
stage four advanced metastatic cancer or associated condition
Preferred products
- Imbruvica 140 mg capsules
Initial criteria
- (A) Diagnosis of stage four advanced metastatic cancer confirmed by prescriber statement or documentation AND use for cancer or associated condition AND use consistent with best practices, supported by peer-reviewed, evidence-based literature, and FDA approved OR
- (B) Patient is currently being treated and stable on requested agent [chart notes required] OR
- (C) Tried and had inadequate response to Imbruvica 140 mg capsules [chart notes required] OR
- (D) Imbruvica 140 mg capsules discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR
- (E) Intolerance or hypersensitivity to Imbruvica 140 mg capsules not expected with Imbruvica tablets [chart notes required] OR
- (F) FDA labeled contraindication to Imbruvica 140 mg capsules not expected with tablets [chart notes required] OR
- (G) Imbruvica capsules expected to be ineffective, cause adherence barrier, worsen comorbid condition, reduce functional ability, or cause harm [chart notes required] OR
- (H) Imbruvica capsules not in best interest based on medical necessity [chart notes required] OR
- (I) Tried another drug in same class/mechanism as Imbruvica capsules and discontinued due to lack of efficacy or adverse event [chart notes required] OR
- (J) Support for use of Imbruvica tablets over Imbruvica 140 mg capsules [chart notes required]