Votrient — Blue Cross Blue Shield of Oklahoma
stage four advanced metastatic cancer or associated condition
Preferred products
- everolimus
- imatinib
- gefitinib
- sorafenib tosylate
- dasatinib
- sunitinib
- erlotinib
- bexarotene
- temozolomide
- lapatinib
- pazopanib
- capecitabine
- abiraterone
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 associated condition AND
- 2. Use of requested agent consistent with best practices supported by peer-reviewed literature and FDA approval OR
- B. Currently treated and stable on requested agent OR
- C. Tried and had inadequate response to generic equivalent OR
- D. Generic equivalent discontinued due to lack of efficacy or adverse event OR
- E. Intolerance or hypersensitivity to generic equivalent not expected to occur with brand agent