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The Policy VaultThe Policy Vault

Ogsiveo — Blue Cross Blue Shield of Montana

Advanced or metastatic breast cancer

Preferred products

  • Kisqali
  • Kisqali Femara Pack
  • Ibrance
  • Verzenio
  • imatinib (generic)
  • dasatinib (generic)
  • sorafenib (generic)
  • Rozlytrek
  • Xalkori

Initial criteria

  • Target Agent(s) will be approved when ALL of the following are met:
  • 1. ONE of the following:
  • A. The patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  • B. ALL of the following:
  • 1. ONE of the following: A. The patient has an FDA labeled indication for the requested agent and route of administration OR B. The patient has an indication that is supported in compendia for the requested agent and route of administration (indication must be supported in compendia by ALL requirements such as performance status, disease severity, previous failures, monotherapy vs. combination therapy)
  • 2. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication
  • 3. ONE of the following: A. The requested indication does NOT require specific genetic/diagnostic testing per FDA labeling or compendia OR B. The requested indication requires specific genetic/diagnostic testing and BOTH of the following: 1. Testing has been completed AND 2. Results indicate therapy with the requested agent is appropriate
  • 4. ONE of the following: A. The requested agent will be used as monotherapy AND is supported for use as monotherapy within FDA labeling or compendia OR B. The requested agent will be used as combination therapy AND is supported as such within FDA labeling or compendia
  • 5. ONE of the following: A. The patient has stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer or associated condition; and the use is consistent with best practices and FDA approval OR B. The requested agent will be used as first-line therapy and is a first-line agent within FDA labeling or compendia OR C. The patient has tried and had an inadequate response to the appropriate prerequisite agents OR D. The patient has an intolerance or hypersensitivity to the appropriate prerequisite agents OR E. The patient has an FDA labeled contraindication to ALL required prerequisite agents
  • 6. ONE of the following: A. The requested agent is a preferred agent for the requested indication OR B. The requested agent is a non-preferred agent for the requested indication AND ONE of the following applies: patient is stable on current therapy, has failed, not tolerated, or contraindicated to at least one preferred agent, or preferred agent inappropriate/not in best interest per medical necessity or clinical predictability, or NCCN supports requested agent as preferred regimen
  • 7. If the requested agent is Bosulif capsules, specific dosing and justification criteria apply (dose < 500mg OR comprehensive justification for use over oral tablets) including prior response, tolerance, or necessity due to swallowing difficulties
  • 8. If the requested agent is Imbruvica 140mg or 280mg tablets, specific stage four advanced metastatic cancer documentation applies