Qudexy xr — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) patient has diagnosis of migraine OR (B) ONE of the following: (1) patient has ONE of the following diagnoses: partial onset seizures OR primary generalized tonic-clonic seizures OR Lennox-Gastaut Syndrome OR (2) patient has medication history of use of an anti-seizure medication that is not topiramate OR (C) patient has another FDA labeled indication for the requested agent and route of administration OR (D) patient has another indication that is supported in compendia for the requested agent and route of administration
• If the patient has an FDA labeled indication, then ONE of the following: (A) patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) there is support for using the requested agent for the patient’s age for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• Alternate approval path: (1) Request is for a BCBS NM Fully Insured or NM HIM member AND ALL of the following: patient does NOT have any FDA labeled contraindications AND indication is a rare disease AND ONE of the following: another FDA labeled indication OR indication supported in compendia; OR (2) ALL of the following: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient does NOT have contraindications AND ONE of the following: another FDA labeled indication OR indication supported in compendia OR prescriber submitted TWO peer-reviewed journal articles supporting the use

Reauthorization criteria

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

Approval duration

12 months