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The Policy VaultThe Policy Vault

Seysara — Blue Cross Blue Shield of Oklahoma

rosacea

Preferred products

  • doxycycline monohydrate capsule
  • doxycycline hyclate capsule
  • doxycycline hyclate tablet
  • doxycycline monohydrate suspension
  • minocycline hydrochloride capsule
  • minocycline hydrochloride tablet
  • minocycline hydrochloride extended-release tablet
  • tetracycline HCL capsule
  • tetracycline HCL tablet

Initial criteria

  • ONE of the following:
  • A. The prescriber states the patient has been treated with the requested agent (starting on samples is NOT approvable) 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 the 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 for the requested agent OR
  • B. There is support of using the requested agent for the patient’s age for the requested 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 been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • 2. 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 related condition, supported by peer-reviewed evidence-based literature, and FDA approved OR
  • 2. The patient has ONE of the following:
  • A. Tried and had inadequate response to ONE prerequisite agent within the past 90 days [chart notes required] OR
  • B. ONE prerequisite agent was discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • C. Has intolerance or hypersensitivity to ONE prerequisite agent not expected to occur with requested agent [chart notes required] OR
  • D. ONE prerequisite is expected to be ineffective, cause adherence barrier, worsen comorbid condition, decrease function, or cause harm [chart notes required] OR
  • E. ONE prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • F. Tried another drug in same class as ONE prerequisite with lack of efficacy or adverse event [chart notes required] OR
  • G. Has contraindication to ALL prerequisite agents not expected with requested agent [chart notes required] OR
  • 3. There is support that ALL prerequisite agent(s) are NOT appropriate for 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. 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. 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 [chart notes required] AND
  • B. The use of the requested agent is consistent with best practices, supported by evidence-based literature, and FDA approved OR
  • 2. The patient has ONE of the following:
  • A. Tried and had inadequate response to ONE prerequisite agent in past 180 days [chart notes required] OR
  • B. ONE prerequisite discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • C. Intolerance or hypersensitivity to ONE prerequisite agent not expected to occur with requested agent [chart notes required] OR
  • D. ONE prerequisite expected ineffective, causes adherence barrier, worsen comorbid, or cause harm [chart notes required] OR
  • E. ONE prerequisite 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. Has contraindication to ALL prerequisite agents not expected to occur with requested agent [chart notes required] OR
  • 3. There is support that ALL prerequisite agent(s) are NOT appropriate for requested indication
  • AND if the patient has acne:
  • A. Will use benzoyl peroxide agent OR retinoid agent in combination OR
  • B. Has intolerance, hypersensitivity, or contraindication to benzoyl peroxide or retinoid agent
  • AND if patient has acne or rosacea:
  • The patient will NOT use requested agent with another tetracycline derivative for acne or rosacea
  • AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Same as initial criteria

Approval duration

36 months (BCBSOK); 12 months (others)