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glutamine (sickle cell) — Blue Cross Blue Shield of New Mexico

sickle cell disease

Preferred products

  • L-glutamine

Initial criteria

  • The patient has a diagnosis of sickle cell disease AND
  • The patient is using the requested agent to reduce the acute complications of sickle cell disease AND
  • 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 OR (B) There is support for using the requested agent for the patient’s age for the requested indication AND
  • ONE of the following: (A) The patient has tried and had an inadequate response after at least 6 months duration of therapy with maximally tolerated hydroxyurea [medical records including chart notes required] OR (B) The patient has an intolerance or hypersensitivity to hydroxyurea OR (C) The patient has an FDA labeled contraindication to hydroxyurea AND
  • ONE of the following: (A) The patient will NOT be using the requested agent in combination with Adakveo (crizanlizumab-tmca) OR (B) There is support for use of the requested agent in combination with Adakveo (crizanlizumab-tmca) AND
  • If the request is for a brand agent with an available generic equivalent (Endari/L-glutamine), then ONE of the following: (A) The request is for a BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR (B) The patient is currently being treated with and stable on the brand OR (C) The patient has tried and had an inadequate response to the generic equivalent OR (D) The generic equivalent was discontinued due to lack of efficacy, diminished effect, or an adverse event OR (E) The patient has an intolerance or hypersensitivity to the generic equivalent not expected with brand OR (F) The patient has a contraindication to the generic equivalent not expected with brand OR (G) The generic equivalent is expected to be ineffective, cause barriers to adherence, worsen comorbid condition, decrease functional ability, cause adverse reaction, or cause harm OR (H) The generic equivalent is not in the patient’s best interest based on medical necessity OR (I) The patient has tried another drug in the same class discontinued due to lack of efficacy, diminished effect, or adverse event OR (J) There is support for use of brand over generic equivalent AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication
  • Length of Approval: 12 months
  • The requested agent will also be approved when ONE of the following is met: (1) The request is for a BCBS NM Fully Insured or NM HIM member and ALL of: (A) No contraindications, (B) Requested indication is a rare disease, (C) ONE of: another FDA labeled indication for the same route OR indication supported in compendia OR (2) ALL of the following: (A) The member resides in Ohio, (B) The plan is Fully Insured or HIM Shop (SG), (C) No contraindications, (D) ONE of: another FDA labeled indication for same route OR indication supported in compendia OR prescriber submitted two supporting peer-reviewed journal articles meeting criteria.

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • The patient has had clinical benefit with the requested agent (e.g., reduction in acute complications of sickle cell disease since initiating therapy) AND
  • ONE of the following: (A) The patient will NOT be using the requested agent in combination with Adakveo (crizanlizumab-tmca) OR (B) There is support for use of the requested agent in combination with Adakveo (crizanlizumab-tmca) AND
  • If the request is for a brand agent with an available generic equivalent (Endari/L-glutamine), then ONE of the following: (A) Member is BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties OR (B) Stable on brand agent OR (C) Tried and inadequate response to generic equivalent OR (D) Generic discontinued due to inefficacy or adverse event OR (E) Intolerance or hypersensitivity to generic not expected with brand OR (F) Contraindication to generic not expected with brand OR (G) Generic expected to be ineffective, cause adherence barriers, worsen comorbidity, decrease function, cause adverse reaction, or harm OR (H) Generic not in best interest of patient OR (I) Tried another drug in same class discontinued due to poor efficacy or adverse event OR (J) Support for brand use over generic OR
  • The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication
  • Length of Approval: 12 months

Approval duration

12 months