Treximet — Blue Cross Blue Shield of Montana

Preferred products

• Generic isotretinoin (Claravis, Amnesteem, Zenatane, Myorisan, Accutane)
• Tretinoin
• Tazarotene cream
• Generic hydrocortisone cream 2.5%
• Hydrocortisone lotion 2.5%
• Generic brimonidine 0.2% ophthalmic solution
• Generic cyclobenzaprine 5mg, 10mg tablets
• Generic tizanidine 2mg, 4mg tablets
• Chlorzoxazone tab 500 mg

Initial criteria

• 1. The patient has an FDA labeled or Compendia approved indication for the requested agent AND
• 2. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• 3. ONE of the following:
• A. BOTH of the following: (1) The patient has stage 4 advanced metastatic cancer and the requested agent is being used to treat the cancer or associated condition; AND (2) Use is consistent with best practices and FDA approval OR
• B. The patient is currently being treated with the requested agent and is stable on therapy [chart notes required] OR
• C. The patient has tried and had an inadequate response to optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative [chart notes required] OR
• D. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative was discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR
• E. The patient has intolerance or hypersensitivity to ONE more cost-effective, clinically appropriate, formulary alternative [chart notes required] OR
• F. The patient has an FDA labeled contraindication to ONE more cost-effective, clinically appropriate, formulary alternative [chart notes required] OR
• G. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative is expected ineffective or worsen condition/adherence or cause harm [chart notes required] OR
• H. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative is 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 mechanism of action and it was discontinued due to lack of efficacy or adverse event [chart notes required]
• Compendia allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• ALSO covered if BCBS NM Fully Insured or NM HIM member with rare disease indication meeting all criteria or Fully Insured/HIM Ohio member meeting requirements including compendia or peer-reviewed support

Reauthorization criteria

• 1. The patient was previously approved for the requested agent through Prime Therapeutics Prior Authorization process in the previous 18 months

Approval duration

12 months