eliglustat — Blue Cross Blue Shield of Montana

Initial criteria

• The requested brand drug cannot be substituted with a generic equivalent when: the generic causes significant barrier to adherence, worsens a comorbid condition, decreases functional ability, or causes adverse reaction or physical/mental harm (chart notes required) OR
• The generic equivalent is not in the best interest of the patient based on medical necessity (chart notes required) OR
• The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as the generic equivalent and the prescription drug was discontinued due to lack of efficacy, diminished effect, or adverse event (chart notes required) OR
• There is support for the use of the requested brand agent over the generic equivalent AND
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist) or has consulted with such a specialist AND
• The patient will NOT be using the requested agent in combination with another substrate reduction therapy agent (e.g., Cerdelga, eliglustat, Opfolda) for the requested indication AND
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months