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VMAT2 Inhibitors — Blue Cross Blue Shield of Montana

tardive dyskinesia

Initial criteria

  • Prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND the use is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and FDA approved OR
  • Patient is currently being treated with the requested agent and is stable on the requested agent [chart notes required] OR
  • Patient has tried and had an inadequate response to the generic equivalent [chart notes required] OR
  • Generic equivalent was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
  • Patient has intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent [chart notes required] OR
  • Patient has FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent [chart notes required] OR
  • Generic equivalent expected to be ineffective based on known patient or drug characteristics, cause adherence barrier, worsen comorbid condition, decrease functional ability, or cause adverse reaction/physical or mental harm [chart notes required] OR
  • Generic equivalent not in best interest of patient based on medical necessity [chart notes required] OR
  • Patient has tried another prescription drug in same pharmacologic class or mechanism as the generic equivalent and discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • There is support for use of requested brand agent over the generic equivalent AND
  • Patient will NOT use the requested agent in combination with another VMAT2 Inhibitor for the requested indication AND
  • Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months