Imbruvica tablets — Blue Cross Blue Shield of Texas
stage four advanced metastatic cancer or associated condition
Preferred products
- Imbruvica 140 mg capsules
Initial criteria
- ONE of the following:
- A. BOTH of the following: 1. Prescriber has stated or documented diagnosis of stage four advanced, metastatic cancer and requested agent is used to treat the cancer or associated condition; AND 2. Use is consistent with best practices for treatment, supported by peer-reviewed evidence, and FDA approved.
- B. Patient is currently being treated and stable on requested agent [chart notes required].
- C. Patient has tried and had an inadequate response to Imbruvica 140 mg capsules [chart notes required].
- D. Imbruvica 140 mg capsules discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required].
- E. Intolerance or hypersensitivity to Imbruvica 140 mg capsules not expected with Imbruvica tablets [chart notes required].
- F. FDA labeled contraindication to Imbruvica 140 mg capsules not expected with Imbruvica tablets [chart notes required].
- G. Imbruvica capsules expected ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, cause harm [chart notes required].
- H. Imbruvica capsules not in best interest of patient based on medical necessity [chart notes required].
- I. Patient has tried another drug in same class or mechanism as Imbruvica capsules and discontinued due to inefficacy or adverse event [chart notes required].
- J. Support for use of requested agent over Imbruvica 140 mg capsules [chart notes required].