Imbruvica tablets — Blue Cross Blue Shield of New Mexico
stage four advanced metastatic cancer or associated condition
Preferred products
- Imbruvica 140 mg capsules
Initial criteria
- ONE of the following:
- A. BOTH of the following: 1. Diagnosis of stage four advanced metastatic cancer or associated condition AND 2. Use is consistent with best practices and FDA approved
- B. Patient is currently treated and stable on requested agent [chart notes required]
- C. Tried and inadequate response to Imbruvica 140 mg capsules [chart notes required]
- D. Imbruvica 140 mg capsules discontinued due to lack of efficacy or adverse event [chart notes required]
- E. Intolerance or hypersensitivity to Imbruvica 140 mg capsules not expected with requested agent [chart notes required]
- F. FDA labeled contraindication to Imbruvica 140 mg capsules not expected with requested agent [chart notes required]
- G. Imbruvica capsules expected to be ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required]
- H. Imbruvica capsules not in best interest based on medical necessity [chart notes required]
- I. Tried another drug in same class as Imbruvica capsules discontinued for inefficacy or adverse effect [chart notes required]
- J. Support for use of requested agent over Imbruvica 140 mg capsules