Drizalma — Blue Cross Blue Shield of Oklahoma

Preferred products

• duloxetine delayed-release
• amitriptyline
• nortriptyline
• desipramine
• imipramine
• gabapentin
• cyclobenzaprine
• tramadol
• acetaminophen
• oral NSAID
• topical NSAID

Initial criteria

• Target Agent(s) will be approved when ONE of the following is met:
• 1. BOTH of the following:
• A. ONE of the following:
• 1. The 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
• 2. The 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
• B. The use of the requested agent 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 approved by the FDA OR
• 2. ONE of the following:
• A. The patient has been treated with the requested agent within the past 180 days OR
• B. The prescriber states the patient is currently being treated with the requested agent and is currently stable [chart notes required] OR
• C. ONE of the following applies:
• 1. The patient has tried and had an inadequate response to a generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
• 2. The patient has an intolerance or hypersensitivity to a generic antidepressant [chart notes required] OR
• 3. The patient has an FDA-labeled contraindication to ALL generic antidepressants [chart notes required] OR
• D. The patient has a diagnosis of neuropathic pain and ONE of the following:
• 1. Tried and had inadequate response to ONE prerequisite (duloxetine DR, amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) [chart notes required] OR
• 2. Intolerance or hypersensitivity to ONE prerequisite agent [chart notes required] OR
• 3. FDA-labeled contraindication to ALL prerequisite agents [chart notes required] OR
• E. The patient has a diagnosis of fibromyalgia and ONE of the following:
• 1. Tried and had inadequate response to ONE prerequisite (duloxetine DR, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) [chart notes required] OR
• 2. Intolerance or hypersensitivity to ONE prerequisite agent [chart notes required] OR
• 3. Contraindication to ALL prerequisite agents [chart notes required] OR
• F. The patient has chronic musculoskeletal pain and ONE of the following:
• 1. Tried and had inadequate response to ONE prerequisite (duloxetine DR, acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin) [chart notes required] OR
• 2. Intolerance or hypersensitivity to ONE prerequisite agent [chart notes required] OR
• 3. Contraindication to ALL prerequisite agents [chart notes required] OR
• G. A prerequisite agent was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
• H. A prerequisite agent is expected to be ineffective, cause adherence barriers, worsen a comorbid condition, impair daily activities, or cause harm [chart notes required] OR
• I. A prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
• J. The patient has tried a drug in the same class as a prerequisite and discontinued due to lack of efficacy or adverse event [chart notes required] OR
• K. If used for a diagnosis other than neuropathic pain, fibromyalgia, or musculoskeletal pain, ONE of the following:
• 1. The patient has an intolerance or hypersensitivity to a generic antidepressant OR
• 2. The patient has an FDA-labeled contraindication to ALL generic antidepressants

Approval duration

12 months