abiraterone 500 mg — Blue Cross Blue Shield of Texas
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. Prescriber has stated or documented stage four advanced metastatic cancer and requested agent treats cancer or associated condition; AND 2. Use consistent with best practices, supported by evidence, FDA approved.
- B. Patient currently treated and stable on requested agent [chart notes required].
- C. Tried and inadequate response to generic abiraterone 250 mg tablets [chart notes required].
- D. Generic abiraterone 250 mg discontinued due to lack of efficacy or adverse event [chart notes required].
- E. Intolerance or hypersensitivity to generic abiraterone tablets not expected with requested agent [chart notes required].
- F. FDA labeled contraindication to generic abiraterone tablets not expected with requested agent [chart notes required].
- G. Generic abiraterone tablets expected ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required].
- H. Generic abiraterone tablets not in best interest of patient [chart notes required].
- I. Tried another drug in same class or mechanism as abiraterone tablets and discontinued due to inefficacy or adverse event [chart notes required].
- J. Support for use of requested agent over generic abiraterone 250 mg tablets.