Diclegis — Blue Cross Blue Shield of Alabama

Initial criteria

• The requested agent is being used to treat pregnancy related nausea or vomiting (not including hyperemesis gravidarum) OR the patient has another FDA labeled indication for the requested agent and route of administration
• There is support that the use of the individual ingredients within the target combination agent as separate dosage forms is not clinically appropriate for the patient
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

up to due date of pregnancy