Imkeldi — Blue Cross Blue Shield of Montana

stage four advanced metastatic cancer or associated condition

Preferred products

(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 imatinib tablets [chart notes required] OR
(D) Imatinib tablets discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR
(E) Intolerance/hypersensitivity to imatinib tablets not expected with requested agent [chart notes required] OR
(F) FDA labeled contraindication to imatinib tablets not expected with requested agent [chart notes required] OR
(G) Imatinib tablets expected to be ineffective, cause adherence barrier, worsen comorbid condition, reduce daily function, or cause harm [chart notes required] OR
(H) Imatinib tablets not in best interest based on medical necessity [chart notes required] OR
(I) Tried another drug in same class/mechanism as imatinib tablets and discontinued due to lack of efficacy or adverse event [chart notes required] OR
(J) Support for use of requested agent over imatinib tablets (e.g., swallowing difficulties)