Mekinist oral solution — Blue Cross Blue Shield of Texas
stage four advanced metastatic cancer or associated condition
Preferred products
- Mekinist oral tablets
Initial criteria
- ONE of the following:
- A. Patient weight < 26 kg.
- B. 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.
- C. Patient currently treated and stable on requested agent [chart notes required].
- D. Tried and inadequate response to Mekinist oral tablets [chart notes required].
- E. Mekinist oral tablets discontinued due to lack of efficacy or adverse event [chart notes required].
- F. Intolerance or hypersensitivity to Mekinist oral tablets not expected with requested agent [chart notes required].
- G. FDA labeled contraindication to Mekinist oral tablets not expected with requested agent [chart notes required].
- H. Mekinist oral tablets expected ineffective, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause harm [chart notes required].
- I. Mekinist oral tablets not in best interest of patient [chart notes required].
- J. Tried another drug in same class or mechanism as Mekinist tablets and discontinued due to inefficacy or adverse event [chart notes required].
- K. Support for use of requested agent over Mekinist oral tablets (e.g., swallowing difficulties).