Rayos — Blue Cross Blue Shield of Montana

Preferred products

• generic oral prednisone
• dexamethasone
• methylprednisolone
• prednisolone

Initial criteria

• The patient has an FDA labeled indication for Rayos AND
• The patient's age is within FDA labeling for the requested indication OR there is support for use at that age AND
• ONE of the following:
• A. The patient has stage four advanced, metastatic cancer and Rayos is being used to treat the cancer OR an associated condition, supported by chart notes AND the use is consistent with best practices and FDA approval OR
• B. The patient is currently being treated with Rayos and is stable on therapy [chart notes required] OR
• C. The patient has tried and had an inadequate response to BOTH a generic oral prednisone AND at least one other different generic oral corticosteroid (e.g., dexamethasone, methylprednisolone, prednisolone) [chart notes required] OR
• D. Both a generic oral prednisone AND at least one other different generic oral corticosteroid were discontinued due to lack of efficacy, effectiveness, diminished effect, or an adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to BOTH a generic oral prednisone AND at least one other different generic oral corticosteroid that is not expected to occur with Rayos [chart notes required] OR
• F. The patient has an FDA labeled contraindication to ALL generic oral corticosteroids that is not expected to occur with Rayos [chart notes required] OR
• G. Generic oral prednisone AND at least one other different generic oral corticosteroid are expected to be ineffective, cause significant adherence barriers, worsen comorbid conditions, decrease functional ability, or cause harm [chart notes required] OR
• H. Generic oral prednisone AND at least one other different generic oral corticosteroid are not in the best interest of the patient based on medical necessity [chart notes required] OR
• I. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as generic oral prednisone AND at least one other corticosteroid, and discontinued due to lack of efficacy or adverse event [chart notes required] AND
• The patient does NOT have any FDA labeled contraindications to Rayos.

Reauthorization criteria

• Continuation of therapy may be approved if the patient is currently being treated with Rayos and remains stable on the medication [chart notes required].

Approval duration

12 months (BCBSIL); 6 months (other plans)