Imkeldi — Blue Cross Blue Shield of Texas
stage four advanced metastatic cancer or associated condition
Preferred products
- imatinib 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 the cancer or associated condition; AND 2. Use consistent with best practices, supported by evidence, FDA approved.
- B. Patient is currently treated and stable on requested agent [chart notes required].
- C. Patient has tried and had inadequate response to imatinib tablets [chart notes required].
- D. Imatinib tablets discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required].
- E. Intolerance or hypersensitivity to imatinib tablets not expected with Imkeldi [chart notes required].
- F. FDA labeled contraindication to imatinib tablets not expected with requested agent [chart notes required].
- G. Imatinib tablets expected ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required].
- H. Imatinib tablets not in best interest of patient [chart notes required].
- I. Tried another drug in same class or mechanism as imatinib and discontinued due to inefficacy or adverse event [chart notes required].
- J. Support for use of requested agent over imatinib tablets (e.g., swallowing difficulties).