Skip to content
The Policy VaultThe Policy Vault

Minolira — Blue Cross Blue Shield of Illinois

acne

Preferred products

  • doxycycline monohydrate capsule
  • doxycycline hyclate tablet
  • doxycycline monohydrate tablet
  • doxycycline hyclate capsule
  • doxycycline suspension
  • Vibramycin
  • Doryx
  • Doryx MPC
  • minocycline hydrochloride capsule
  • minocycline hydrochloride tablet
  • Minolira
  • Solodyn
  • Emrosi
  • minocycline HCL capsule
  • tetracycline HCL capsule

Initial criteria

  • ONE of the following: (A) The prescriber states the patient has been treated with the requested agent (starting on samples is NOT approvable) within the past 90 days AND is at risk if therapy is changed OR (B) ALL of the following:
  • 1. ONE of the following: (A) The requested agent is being used off-label for the treatment of a tick-borne disease OR (B) BOTH of the following: (1) The patient has an FDA labeled indication for the requested agent and route of administration AND (2) If the patient has an FDA approved indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support of using the requested agent for the patient’s age for the requested indication.
  • 2. ONE of the following: (A) The requested agent is a doxycycline agent or Seysara AND ONE of the following: (1) BOTH of the following: (A) ONE of the following: (1) The prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR (2) The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND (B) The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by FDA OR (2) The patient has ONE of the following: (A) Tried and had an inadequate response to ONE prerequisite agent within the past 90 days [chart notes required] OR (B) ONE prerequisite agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or adverse event [chart notes required] OR (C) Has an intolerance or hypersensitivity to ONE prerequisite agent not expected to recur with the requested agent [chart notes required] OR (D) ONE prerequisite agent is expected to be ineffective or causes adherence barrier or worsens condition [chart notes required] OR (E) ONE prerequisite agent is not in best interest of patient [chart notes required] OR (F) Tried another drug same class as prerequisite discontinued due to lack of efficacy/effect or adverse event [chart notes required] OR (G) Has an FDA labeled contraindication to ALL prerequisite agents not expected with requested agent [chart notes required] OR (3) There is support that ALL prerequisite agents are NOT appropriate for the requested indication.
  • (B) The requested agent is a minocycline agent or tetracycline agent AND ONE of the following: (1) BOTH of the following: (A) ONE of the following: (1) The prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR (2) The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND (B) The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by FDA OR (2) The patient has ONE of the following: (A) Tried and had inadequate response to ONE prerequisite agent in the past 180 days [chart notes required] OR (B) ONE prerequisite agent discontinued due to lack of efficacy, effectiveness, diminished effect, or adverse event [chart notes required] OR (C) Intolerance or hypersensitivity to ONE prerequisite agent not expected to occur with requested agent [chart notes required] OR (D) ONE prerequisite agent expected to be ineffective or cause adherence barrier or worsen condition [chart notes required] OR (E) ONE prerequisite agent not in best interest based on medical necessity [chart notes required] OR (F) Tried another drug in same class as ONE prerequisite agent discontinued due to lack of efficacy or adverse event [chart notes required] OR (G) FDA labeled contraindication to ALL prerequisite agents not expected with requested agent [chart notes required] OR (3) There is support that ALL prerequisite agents are NOT appropriate for the requested indication.
  • If diagnosis is acne, ONE of the following: (A) The patient will use a benzoyl peroxide or retinoid agent in combination with the requested agent OR (B) The patient has intolerance, hypersensitivity, or contraindication to a benzoyl peroxide or retinoid agent.
  • If diagnosis is acne or rosacea, patient will NOT use requested agent in combination with another tetracycline derivative for those indications.
  • The patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months (36 months for BCBSOK)