Zytiga 500 mg (abiraterone 500 mg) — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following:
• A. BOTH of:
• 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
• B. Patient currently treated and stable on requested agent [chart notes required]
• C. Patient tried and had inadequate response to generic abiraterone 250 mg [chart notes required]
• D. Generic abiraterone 250 mg discontinued due to lack of efficacy, effectiveness, diminished effect, or adverse event [chart notes required]
• E. Patient has intolerance or hypersensitivity to generic abiraterone 250 mg not expected with requested agent [chart notes required]
• F. Patient has FDA labeled contraindication to generic abiraterone 250 mg not expected with requested agent [chart notes required]
• G. Generic abiraterone 250 mg expected to be ineffective OR cause adherence barrier OR worsen comorbidities OR decrease functional ability OR cause harm [chart notes required]
• H. Generic abiraterone 250 mg not in best interest of patient based on medical necessity [chart notes required]
• I. Patient tried another drug in same class or mechanism as abiraterone 250 mg discontinued due to lack of efficacy, effectiveness, or adverse event [chart notes required]
• J. Support for use of requested agent over generic abiraterone 250 mg

Approval duration

12 months