Nuedexta — Blue Cross Blue Shield of Kansas

Initial criteria

• 1. The patient has a diagnosis of pseudobulbar affect (PBA) AND
• 2. The patient has ONE of the following: A. Amyotrophic lateral sclerosis (ALS) OR B. Multiple sclerosis (MS) OR C. Dementia OR D. Stroke OR E. Traumatic brain injury AND
• 3. The prescriber has assessed the patient's PBA episodes (laughing and/or crying episodes) prior to therapy with the requested agent AND
• 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

initial 3 months; renewal 12 months