Imkeldi — Blue Cross Blue Shield of New Mexico
stage four advanced metastatic cancer or associated condition
Preferred products
- imatinib tablets
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 consistent with best practices and FDA-approved therapy
- B. Patient is currently treated and stable on requested agent [chart notes required]
- C. Tried and inadequate response to imatinib tablets [chart notes required]
- D. Imatinib tablets discontinued due to lack of efficacy or adverse event [chart notes required]
- E. Intolerance or hypersensitivity to imatinib tablets not expected to occur with requested agent [chart notes required]
- F. FDA contraindication to imatinib tablets not expected to occur with requested agent [chart notes required]
- G. Imatinib tablets expected to be ineffective or cause adherence barrier or harm [chart notes required]
- H. Imatinib tablets not in best interest of patient based on medical necessity [chart notes required]
- I. Tried another drug in same pharmacologic class as imatinib discontinued for inefficacy or adverse effect [chart notes required]
- J. Support for use of requested agent over imatinib tablets (e.g., swallowing difficulties)