dextromethorphan hbr-quinidine sulfate — Blue Cross Blue Shield of Montana

pseudobulbar affect (PBA)

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

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

12 months (BCBSIL); 3 months (others initial, renewal 12 months)