Afinitor Disperz (everolimus tablets for oral suspension) — Highmark

TSC with subependymal giant cell astrocytoma (SEGA) that cannot be curatively resected

Preferred products

For TSC with SEGA: age ≥ 1 year AND diagnosis of TSC with SEGA AND not a candidate for curative surgical resection AND (failed or intolerant to plan-preferred generic everolimus tablets OR unable to swallow generic everolimus tablets) AND if brand Afinitor Disperz requested, failed or intolerant to generic everolimus tablets for suspension
For TSC-associated partial-onset seizures: age ≥ 2 years AND using Afinitor Disperz as adjunctive treatment for TSC-associated partial-onset seizures AND if brand Afinitor Disperz requested, failed or intolerant to generic everolimus tablets for suspension

Prescriber attests member is tolerating therapy AND has shown a therapeutic response defined as disease improvement or delayed disease progression
If brand Afinitor Disperz requested, documentation that AB-rated generic is ineffective or not tolerated

24 months