Mekinist oral solution — Blue Cross Blue Shield of Texas

stage four advanced, metastatic cancer

Initial criteria

ONE of the following:
A. Patient weighs less than 26 kg OR
B. BOTH of the following:
1. Prescriber states or documents stage four advanced, metastatic cancer and requested agent used to treat it OR associated condition [chart notes required]
2. Use consistent with best practices, supported by evidence-based literature, and FDA approved
C. Patient currently treated and stable on requested agent [chart notes required]
D. Patient tried and had inadequate response to Mekinist oral tablets [chart notes required]
E. Mekinist tablets discontinued due to lack of efficacy, effectiveness, diminished effect, or adverse event [chart notes required]
F. Patient has intolerance or hypersensitivity to Mekinist tablets not expected with requested agent [chart notes required]
G. Patient has FDA labeled contraindication to Mekinist tablets not expected with requested agent [chart notes required]
H. Mekinist tablets expected to be ineffective OR cause adherence barrier OR worsen comorbidities OR decrease functional ability OR cause harm [chart notes required]
I. Mekinist tablets not in best interest of patient based on medical necessity [chart notes required]
J. Patient tried another drug in same class as Mekinist tablets discontinued for lack of efficacy or adverse event [chart notes required]
K. Support for use of requested agent over Mekinist tablets (e.g., swallowing difficulties)

12 months