Qudexy XR — Blue Cross Blue Shield of Alabama

migraine

Initial criteria

ONE of the following: • The patient has a diagnosis of migraine OR • The patient has ONE of the following diagnoses: – Partial onset seizures OR – Primary generalized tonic-clonic seizures OR – Lennox-Gastaut Syndrome OR • The patient has a medication history of use of an anti-seizure medication that is not topiramate OR • The patient has another FDA labeled indication for the requested agent and route of administration OR • The patient has another indication that is supported in compendia for the requested agent and route of administration
AND If the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested indication for the requested agent OR • There is support for using the requested agent for the patient’s age for the requested indication
AND The patient does NOT have any FDA labeled contraindications to the requested agent
Compendia Allowed: AHFS or DrugDex 1 or 2a level of evidence

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND ONE of the following: • The patient has had clinical benefit with the requested agent OR • The patient has a medication history of use of an anti-seizure medication that is not topiramate
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 months