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

stage four advanced, metastatic cancer

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

12 months