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The Policy VaultThe Policy Vault

Bosulif — Blue Cross Blue Shield of Oklahoma

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

Preferred products

  • Kisqali
  • Kisqali Femara Pack
  • Ibrance
  • 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 apply:
  • 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 that is supported in compendia for the requested agent and route of administration (supported in compendia by all requirements including performance status, disease severity, previous failures, monotherapy vs. combination therapy)
  • 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 regarding diagnostic testing: (A) The requested indication does NOT require specific genetic/diagnostic testing OR (B) Required genetic/diagnostic testing has been completed AND the results support use of the requested agent
  • 4. ONE of the following regarding therapy type: (A) The agent will be used as monotherapy and such use is supported in FDA labeling or compendia OR (B) The agent will be used as combination therapy and such use is supported (including all agents/treatments within labeling or compendia)
  • 5. ONE of the following regarding line of therapy and prior treatments: (A) Patient has stage 4 advanced/metastatic cancer and the agent is used to treat the cancer or an associated condition and is consistent with best practices, peer-reviewed evidence, and FDA labeling OR (B) Agent will be used as first-line therapy and is a first-line option in FDA labeling/compendia OR (C) Patient has tried and had inadequate response to prerequisite agents OR (D) Intolerance/hypersensitivity to prerequisite agents OR (E) FDA labeled contraindication to all prerequisite agents
  • 6. ONE of the following regarding formulary status: (A) Requested agent is preferred for the indication OR (B) Requested agent is non-preferred AND one of the following applies: (1) Patient has stage 4 advanced/metastatic cancer as above and use is per best practices OR (2) Patient currently stable on requested agent OR (3) Patient has inadequate response to one preferred agent for the indication OR (4) Preferred agent discontinued due to lack of efficacy or adverse event OR (5) Intolerance/hypersensitivity to one preferred agent OR (6) FDA contraindication to all preferred agents OR (7) Preferred agent expected ineffective or detrimental per clinical characteristics OR (8) Preferred not in patient’s best interest based on medical necessity OR (9) Tried another drug in same class/mechanism as preferred with inadequate response or adverse event OR (10) NCCN does not specify plan preferred agents as preferred regimen but specifies requested agent as preferred regimen OR (11) Support exists for non-preferred over preferred OR (12) If Bosulif or Tasigna for CML, patient previously treated with Bosulif or Tasigna
  • 7. If requested agent is Bosulif capsules, ONE of the following: (A) Dose less than 500 mg OR (B) Meets criteria confirming stage 4 advanced/metastatic cancer use consistent with best practices OR (C) Patient stable on requested agent OR (D) Inadequate response to Bosulif oral tablets OR (E) Bosulif oral tablets discontinued due to inefficacy or adverse event OR (F) Intolerance/hypersensitivity to Bosulif oral tablets not expected with capsules OR (G) Contraindication to Bosulif oral tablets not expected with capsules OR (H) Oral tablets expected ineffective or detrimental OR (I) Oral tablets not in patient’s best interest OR (J) Tried another drug in same class/mechanism and discontinued due to inefficacy/adverse event OR (K) Support for use of capsules over tablets (e.g., swallowing difficulty)