Zytiga — Blue Cross Blue Shield of Texas
stage four advanced metastatic cancer or associated condition
Preferred products
- everolimus
- imatinib
- gefitinib
- sorafenib tosylate
- dasatinib
- sunitinib
- erlotinib
- bexarotene
- temozolomide
- lapatinib
- pazopanib
- capecitabine
- abiraterone
Initial criteria
- Applicable when request is for brand agent with available generic equivalent listed below:
- ONE of the following:
- A. BOTH of the following: 1. Prescriber has stated or documented diagnosis of stage four advanced metastatic cancer and requested agent used to treat cancer or associated condition; AND 2. Use consistent with best practices, supported by peer-reviewed evidence, and FDA approved.
- B. Patient currently treated and stable on requested agent [chart notes required].
- C. Tried and had inadequate response to the generic equivalent [chart notes required].
- D. Generic equivalent discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required].
- E. Intolerance or hypersensitivity to the generic equivalent not expected with brand agent [chart notes required].