Gleevec — Blue Cross Blue Shield of New Mexico

Stage four advanced metastatic cancer or associated condition when brand agent requested and generic equivalent available

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] AND the use is consistent with best practices, supported by evidence-based literature, and FDA approved OR
The patient is currently being treated with the requested brand agent and is stable [chart notes required] OR
The patient has tried and had an inadequate response to the generic equivalent [chart notes required] OR
The generic equivalent was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
The patient has an intolerance or hypersensitivity to the generic equivalent not expected with the brand agent [chart notes required] OR
The patient has an FDA labeled contraindication to the generic equivalent not expected with the brand agent [chart notes required] OR
The generic equivalent expected ineffective, cause adherence barrier, worsen comorbidity, decrease function, or cause harm [chart notes required] OR
The generic equivalent not in best interest of patient [chart notes required] OR
The patient has tried another drug in same class or mechanism as generic equivalent and discontinued for lack of efficacy or adverse event [chart notes required] OR
There is support for use of brand agent over generic equivalent
Patient does not have any FDA labeled contraindications to the requested agent

12 months