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Vibramycin — Blue Cross Blue Shield of Montana

rosacea

Preferred products

  • doxycycline monohydrate capsule
  • doxycycline hyclate capsule
  • doxycycline hyclate tablet
  • doxycycline monohydrate tablet
  • doxycycline hyclate monohydrate suspension
  • minocycline hydrochloride tablet
  • minocycline hydrochloride capsule
  • tetracycline HCL tablet
  • tetracycline HCL capsule

Initial criteria

  • ONE of the following:
  • A. The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR
  • B. ALL of the following:
  • 1. ONE of the following:
  • A. The requested agent is being used off-label for treatment of a tick-borne disease OR
  • B. BOTH of the following:
  • 1. The patient has an FDA labeled indication for the requested agent and route of administration AND
  • 2. If the patient has an FDA approved indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication and agent OR
  • B. There is support of using the requested agent for the patient’s age for the indication
  • 2. ONE of the following:
  • A. The requested agent is a doxycycline agent or Seysara AND ONE of the following:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. The prescriber has stated that the patient has stage IV metastatic cancer and the requested agent is being used to treat the cancer OR
  • 2. Documentation shows use for associated condition related to stage IV metastatic cancer [chart notes required] AND
  • B. The use of the requested agent is consistent with best practices for stage IV cancer and FDA approved OR
  • 2. The patient has ONE of the following:
  • A. Tried and had an inadequate response to ONE prerequisite agent within 90 days [chart notes required] OR
  • B. Prerequisite agent discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • C. Intolerance or hypersensitivity to ONE prerequisite agent not expected with requested agent [chart notes required] OR
  • D. Prerequisite agent expected ineffective or causes adherence barrier or worsens comorbidity or function [chart notes required] OR
  • E. Prerequisite agent not in best interest of patient based on medical necessity [chart notes required] OR
  • F. Tried drug in same class as prerequisite with lack of efficacy or adverse event [chart notes required] OR
  • G. FDA labeled contraindication to ALL prerequisite agents that is not expected with requested agent [chart notes required] OR
  • 3. Support that ALL prerequisite agents are NOT appropriate for the requested indication OR
  • B. The requested agent is a minocycline agent or tetracycline agent AND ONE of the following:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. Stage IV metastatic cancer and requested agent used to treat it OR
  • 2. Documentation that patient has stage IV metastatic cancer with associated condition [chart notes required] AND
  • B. Use consistent with best practices for stage IV cancer and FDA approved OR
  • 2. The patient has ONE of the following:
  • A. Tried and had an inadequate response to ONE prerequisite agent in past 180 days [chart notes required] OR
  • B. Discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • C. Intolerance or hypersensitivity to ONE prerequisite agent not expected with requested agent [chart notes required] OR
  • D. Prerequisite expected ineffective or causes barrier, worsens comorbid condition, or limits function [chart notes required] OR
  • E. Prerequisite agent not in best interest based on medical necessity [chart notes required] OR
  • F. Tried another drug in same class with lack of efficacy or adverse event [chart notes required] OR
  • G. FDA labeled contraindication to ALL prerequisite agents not expected with requested agent [chart notes required] OR
  • 3. Support that ALL prerequisite agents are NOT appropriate for the indication
  • 3. If diagnosis of acne, then ONE of the following:
  • A. The patient will use a benzoyl peroxide agent OR a retinoid in combination with requested agent OR
  • B. The patient has intolerance, hypersensitivity, or contraindication to benzoyl peroxide OR retinoid agent
  • 4. If acne or rosacea, patient will NOT use requested agent in combination with another tetracycline derivative for that condition
  • 5. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (36 months for BCBSOK)