Imbruvica tablets — Blue Cross Blue Shield of Oklahoma
stage four advanced metastatic cancer or associated condition
Preferred products
- Imbruvica 140 mg capsules
Initial criteria
- ONE of the following:
- A. Condition related to stage four advanced metastatic cancer AND use of requested agent consistent with best practices for treatment of stage four metastatic cancer OR
- B. Patient currently treated and stable on requested agent OR
- C. Patient tried and had inadequate response to Imbruvica 140 mg capsules OR
- D. Imbruvica 140 mg capsules discontinued due to lack of efficacy or adverse event OR
- E. Patient has intolerance or hypersensitivity to Imbruvica 140 mg capsules not expected with Imbruvica tablets OR
- F. Patient has FDA labeled contraindication to Imbruvica 140 mg capsules not expected with Imbruvica tablets OR
- G. Imbruvica capsules expected to be ineffective, cause barrier to adherence, worsen comorbid condition, decrease functional ability, or cause harm OR
- H. Imbruvica capsules not in best interest of patient based on medical necessity OR
- I. Patient tried another drug in same pharmacologic class as Imbruvica capsules which was discontinued due to lack of efficacy, diminished effect, or adverse event OR
- J. Support for use of requested agent over Imbruvica capsules