Rayos (prednisone delayed-release tablet) — Blue Cross Blue Shield of New Mexico

Preferred products

• generic oral prednisone
• generic oral corticosteroids (e.g., dexamethasone, methylprednisolone, prednisolone)

Initial criteria

• Patient has an FDA labeled indication for the requested agent AND
• If the patient has an FDA labeled indication, then ONE of the following:
• A. Patient’s age is within FDA labeling for the requested indication for the requested agent 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. BOTH of the following:
• 1. ONE of the following:
• A. Prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
• B. 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
• 2. Use of the requested agent is consistent with best practices for treatment of stage four advanced, metastatic cancer or associated condition; supported by peer-reviewed, evidence-based literature; and approved by the FDA OR
• B. Patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
• C. 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 or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• E. 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 the requested agent [chart notes required] OR
• F. Patient has an FDA labeled contraindication to ALL generic oral corticosteroids that is NOT expected to occur with the requested agent [chart notes required] OR
• G. Generic oral prednisone AND at least one other different generic oral corticosteroid are expected to be ineffective, cause adherence barriers, worsen a comorbid condition, decrease functional ability, or cause adverse reaction or 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. 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 an adverse event [chart notes required] AND
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

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