Zytiga/abiraterone 500 mg — Blue Cross Blue Shield of Oklahoma
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 and requested agent used to treat cancer or associated condition AND
- 2. Use 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 abiraterone 250 mg tablets OR
- D. Generic abiraterone 250 mg tablets discontinued due to lack of efficacy, diminished effect, or adverse event OR
- E. Intolerance or hypersensitivity to generic abiraterone 250 mg tablets not expected with requested agent OR
- F. FDA labeled contraindication to generic abiraterone 250 mg tablets not expected with requested agent OR
- G. Generic abiraterone 250 mg tablets expected to be ineffective, cause adherence barrier, worsen comorbidity, decrease function, or cause harm OR
- H. Generic abiraterone 250 mg tablets not in best interest of patient OR
- I. Tried another drug in same class or mechanism as generic abiraterone 250 mg tablets and discontinued OR
- J. Support for use over generic abiraterone 250 mg tablets