Ogsiveo — Blue Cross Blue Shield of Texas

Advanced or metastatic breast cancer

Preferred products

Kisqali
Kisqali Femara Pack
imatinib (generic)
dasatinib (generic)
sorafenib (generic)
Rozlytrek
Xalkori

Initial criteria

ONE of the following: A. The patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR B. ALL of the following: 1. ONE of the following: A. The patient has an FDA labeled indication for the requested agent and route of administration OR B. The patient has an indication supported in compendia for the requested agent and route of administration (must be supported by all compendia requirements) 2. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication OR B. There is support for using the requested agent for the patient’s age for the requested indication 3. ONE of the following: A. The requested indication does NOT require specific genetic/diagnostic testing OR B. Required testing has been completed and results indicate therapy is appropriate 4. ONE of the following: A. Requested agent will be used as monotherapy AND is supported for use as monotherapy within FDA labeling or compendia OR B. Requested agent will be used as combination therapy AND is supported for such use within FDA labeling or compendia 5. ONE of the following: A. BOTH of the following: 1. Patient has stage four advanced, metastatic cancer or associated condition (documentation required) 2. Use is consistent with best practices and FDA approval OR B. Requested agent used as first-line therapy AND is a first-line agent within FDA labeling or compendia OR C. Patient has tried and had an inadequate response to appropriate prerequisite agents OR D. Patient has intolerance or hypersensitivity to prerequisite agents OR E. Patient has FDA labeled contraindication to ALL prerequisite agents 6. ONE of the following: A. Requested agent is a preferred agent for the indicated condition OR B. Requested agent is a non-preferred agent AND one of the following: 1. Patient has stage four advanced metastatic cancer or associated condition and use is consistent with best practices OR 2. Patient is currently being treated and stable on requested agent OR 3. Patient tried and had inadequate response to ONE preferred agent (documentation required) OR 4. ONE preferred agent discontinued due to lack of efficacy, diminished effect, or adverse event (documentation required) OR 5. Patient has intolerance or hypersensitivity to ONE preferred agent (documentation required) OR 6. Patient has FDA labeled contraindication to ALL preferred agents (documentation required) OR 7. ONE preferred agent expected to be ineffective based on clinical characteristics or cause harm (documentation required) OR 8. ONE preferred agent not in best interest based on medical necessity (documentation required) OR 9. Patient tried another drug in same class as ONE preferred agent that was discontinued due to inefficacy or adverse event (documentation required) OR 10. NCCN does NOT specify plan preferred agent(s) as preferred regimen AND requested agent IS specified as preferred regimen OR 11. Support exists for non-preferred agent over preferred agent(s) OR 12. If requested agent is Bosulif or Tasigna for CML, patient has been previously treated with Bosulif or Tasigna
If requested agent is Bosulif capsules, ONE of the following: A. Requested dose is less than 500 mg OR B. Meets all below: • Patient has stage four advanced metastatic cancer or associated condition and use is consistent with best practices OR C. Patient currently treated and stable on requested agent OR D. Patient had inadequate response to Bosulif oral tablets OR E. Bosulif oral tablets discontinued due to inefficacy/adverse event OR F. Intolerance/hypersensitivity to Bosulif oral tablets OR G. FDA labeled contraindication to Bosulif oral tablets OR H. Bosulif oral tablets expected ineffective or cause harm OR I. Bosulif oral tablets not in best interest based on medical necessity OR J. Patient tried another drug in same class as Bosulif tablets and discontinued due to inefficacy/adverse event OR K. There is support for capsules over tablets (e.g., swallowing difficulties)