Imkeldi — Blue Cross Blue Shield of Oklahoma
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 and requested agent used to treat cancer or an associated condition AND
- 2. Use consistent with best practices supported by peer-reviewed evidence and FDA approval OR
- B. Currently treated and stable on requested agent OR
- C. Tried and had inadequate response to imatinib tablets OR
- D. Imatinib tablets discontinued due to lack of efficacy, diminished effect, or adverse event OR
- E. Intolerance or hypersensitivity to imatinib tablets not expected with requested agent OR
- F. FDA labeled contraindication to imatinib tablets not expected with requested agent OR
- G. Imatinib tablets expected to be ineffective, cause adherence barrier, worsen comorbidity, decrease function, or cause harm OR
- H. Imatinib tablets not in best interest of patient OR
- I. Patient tried another drug in same class or mechanism as imatinib tablets which was discontinued OR
- J. Support for use of requested agent over imatinib tablets