Xhance — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP) OR (B) diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) OR (C) another FDA labeled indication for the requested agent and route of administration OR (D) another indication supported in compendia for the requested agent and route of administration
• If patient has an FDA labeled indication, THEN ONE of the following: (A) patient age is within FDA labeling for requested indication OR (B) support exists for using the requested agent for the patient's age for the requested indication
• ONE of the following: (A) prescriber states patient is currently being treated with and stable on the requested agent [chart notes required] OR (B) patient has tried and had inadequate response to ONE generic or OTC intranasal corticosteroid [chart notes required] OR (C) ONE generic or OTC intranasal corticosteroid discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR (D) patient has intolerance or hypersensitivity to therapy with ONE generic or OTC intranasal corticosteroid not expected to occur with requested agent [chart notes required] OR (E) patient has FDA labeled contraindication to ALL generic and OTC intranasal corticosteroids not expected to occur with requested agent [chart notes required] OR (F) ONE generic or OTC intranasal corticosteroid expected to be ineffective or cause significant barrier/adverse effect as described [chart notes required] OR (G) ONE generic or OTC intranasal corticosteroid not in best interest based on medical necessity [chart notes required] OR (H) patient has tried another prescription drug in same pharmacologic class or with same mechanism of action as ONE generic or OTC intranasal corticosteroid and drug discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required]
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex, level 1, 2a, or 2b evidence
• Alternate approval for BCBS NM Fully Insured or NM HIM member when ALL of the following are met: patient has no FDA labeled contraindications, indication is a rare disease, and (1) patient has another FDA labeled indication OR (2) indication supported in compendia for requested agent and route
• Alternate approval for Ohio Fully Insured or HIM Shop (SG) member when ALL of: member resides in Ohio, plan is Fully Insured/HIM Shop, patient has no FDA labeled contraindications, and (1) patient has another FDA labeled indication OR (2) indication supported in compendia OR (3) prescriber submitted TWO peer-reviewed high-quality journal articles supporting safety and efficacy of use

Reauthorization criteria

• Patient previously approved for requested agent through plan’s PA process
• Patient has had clinical benefit with the requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months