Afinitor (everolimus) — Highmark

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

Preferred products

For breast cancer: prescriber attests member is postmenopausal AND has advanced disease AND disease is hormone receptor-positive, HER2-negative AND used in combination with exemestane AND member has failed letrozole or anastrozole AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets
For pancreatic neuroendocrine tumors: age ≥ 18 years AND diagnosis of progressive PNET that is unresectable, locally advanced, or metastatic AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets
For non-functional neuroendocrine tumors: age ≥ 18 years AND diagnosis of non-functional NET, progressive, well-differentiated, of gastrointestinal or lung origin, unresectable, locally advanced or metastatic AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets
For advanced RCC: age ≥ 18 years AND diagnosis of advanced RCC AND failed sunitinib or sorafenib AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets
For renal angiomyolipoma and TSC: age ≥ 18 years AND diagnosis of renal angiomyolipoma and TSC AND prescriber attests surgery not immediately required AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets
For TSC with SEGA: age ≥ 1 year AND diagnosis of TSC with SEGA AND not a candidate for curative surgical resection AND if brand Afinitor requested, member failed or intolerant to generic everolimus tablets

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

24 months