Zytiga 500 mg — Blue Cross Blue Shield of Montana

Preferred products

• abiraterone 250 mg tablets (generic)

Initial criteria

• 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 generic abiraterone 250 mg tablets [chart notes required]
• OR generic abiraterone 250 mg discontinued due to lack of efficacy, effectiveness, diminished effect, or adverse event [chart notes required]
• OR patient has intolerance, hypersensitivity, or labeled contraindication to generic abiraterone 250 mg not expected with requested agent [chart notes required]
• OR generic abiraterone 250 mg expected to be ineffective or cause adherence/comorbidity/functional/adverse issues [chart notes required]
• OR generic abiraterone 250 mg not in best interest of patient [chart notes required]
• OR patient has tried another drug in same pharmacologic class or mechanism as generic abiraterone 250 mg tablets and discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]
• OR support for use of requested agent over generic abiraterone 250 mg tablets

Approval duration

12 months