Nuedexta — Blue Cross Blue Shield of Alabama

Initial criteria

• - The patient has a diagnosis of pseudobulbar affect (PBA)
• - The patient has ONE of the following underlying conditions: amyotrophic lateral sclerosis (ALS) OR multiple sclerosis (MS) OR dementia OR stroke OR traumatic brain injury
• - The prescriber has assessed the patient's PBA episodes (laughing and/or crying episodes) prior to therapy with the requested agent
• - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist), or has consulted with such a specialist
• - The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• - The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• - The patient has had clinical benefit with the requested agent
• - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist), or has consulted with such a specialist
• - The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 3 months; renewal 12 months