requested agent (imatinib tablet alternatives) — Blue Cross Blue Shield of Texas

Initial criteria

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

Approval duration

12 months