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The Policy VaultThe Policy Vault

Kisqali — Blue Cross Blue Shield of New Mexico

Metastatic ROS1‑positive non‑small cell lung cancer (NSCLC)

Preferred products

  • Kisqali
  • Kisqali Femara Pack
  • Verzenio
  • Imatinib (generic)
  • Dasatinib (generic)
  • Sorafenib (generic)
  • Rozlytrek
  • Xalkori

Initial criteria

  • 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 supported in compendia for the requested agent and route of administration (supported by all listed requirements).
  • 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 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. It requires such testing AND BOTH: (1) testing completed AND (2) results indicate therapy with requested agent is appropriate.
  • 4. ONE of the following: A. Requested agent used as monotherapy AND supported for use as monotherapy within FDA labeling or compendia OR B. Requested agent will be used as combination therapy AND supported for such combination within labeling/compendia.
  • 5. ONE of the following: A. BOTH of the following: (1) Either prescriber statement or documentation that patient has stage IV advanced/metastatic cancer and agent used to treat the cancer/associated condition AND (2) use is consistent with best practices and FDA‑approved OR B. The requested agent will be used as first‑line therapy and is first‑line per labeling/compendia OR C. Patient has tried and had inadequate response to required prerequisite agents OR D. Patient has intolerance/hypersensitivity to required prerequisite agents OR E. Patient has an FDA labeled contraindication to all required prerequisite agents.
  • 6. ONE of the following: A. Requested agent is a preferred agent for the indication OR B. If non‑preferred, ONE of the following: (1) Both A. stage IV advanced cancer documentation AND B. use consistent with best practices OR (2) patient is stable on requested agent OR (3) prior inadequate response to one preferred agent OR (4) preferred discontinued for lack of efficacy/adverse event OR (5) intolerance/hypersensitivity to one preferred OR (6) FDA contraindication to all preferred OR (7) preferred expected to be ineffective/unsafe etc. OR (8) preferred not in best interest based on medical necessity OR (9) prior inadequate response to another drug in same class OR (10) NCCN does not specify plan preferred but does specify requested agent as preferred regimen OR (11) support for non‑preferred over preferred OR (12) if requested Bosulif or Tasigna for CML, patient previously treated with Bosulif or Tasigna).
  • 7. If requested agent is Bosulif capsules, ONE of the following: A. Requested dose <500 mg OR B. BOTH: (1) stage IV advanced cancer documentation AND (2) appropriate use OR C. Patient stable on requested agent OR D. Tried and had inadequate response to Bosulif oral tablets OR E. Bosulif oral tablets discontinued for lack of efficacy/adverse event OR F. Intolerance/hypersensitivity to Bosulif tablets not expected with capsules OR G. FDA contraindication to Bosulif tablets not expected with capsules OR H. Bosulif tablets expected ineffective/unsafe OR I. Bosulif tablets not in best interest OR J. Prior trial of another drug in same class with discontinuation for inefficacy/adverse event OR K. Support for capsule use (e.g., swallowing difficulty).
  • 8. If requested agent is Imbruvica 140 mg or 280 mg tablets, then ONE of the following: BOTH (1) stage IV advanced cancer documentation and (2) appropriate use, or criteria consistent with similar non‑preferred logic.