VMAT2 Inhibitors — Blue Cross Blue Shield of Oklahoma

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 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 United States Food and Drug Administration OR
• Patient is currently being treated with the requested agent and the patient is currently 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
• The generic equivalent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• Patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent [chart notes required] OR
• Patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent [chart notes required] OR
• The generic equivalent is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm [chart notes required] OR
• The generic equivalent is not in the best interest of the patient based on medical necessity [chart notes required] OR
• Patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as the generic equivalent and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• There is support for the use of the requested brand agent over the generic equivalent AND
• Patient will NOT be using the requested agent in combination with another VMAT2 Inhibitor agent for the requested indication AND
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months