Zytiga abiraterone 500 mg — Blue Cross Blue Shield of New Mexico
stage four advanced metastatic cancer or associated condition
Preferred products
- generic abiraterone 250 mg 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 currently treated and stable on requested agent [chart notes required]
- C. Tried and inadequate response to generic abiraterone 250 mg tablets [chart notes required]
- D. Generic abiraterone 250 mg tablets discontinued due to lack of efficacy or adverse event [chart notes required]
- E. Intolerance or hypersensitivity to generic abiraterone 250 mg tablets not expected with requested agent [chart notes required]
- F. FDA contraindication to generic abiraterone 250 mg tablets not expected with requested agent [chart notes required]
- G. Generic abiraterone 250 mg tablets expected to be ineffective or cause adherence barrier or harm [chart notes required]
- H. Generic abiraterone 250 mg tablets not in best interest of patient based on medical necessity [chart notes required]
- I. Tried another drug in same pharmacologic class as generic abiraterone 250 mg tablets discontinued due to inefficacy or adverse effect [chart notes required]
- J. Support for use of requested agent over generic abiraterone 250 mg tablets