Xerese — Blue Cross Blue Shield of Oklahoma

Preferred products

• Generic isotretinoin (Claravis, Amnesteem, Zenatane, Myorisan, Accutane)
• Tretinoin
• Tazarotene cream
• Generic hydrocortisone cream 2.5%
• Hydrocortisone lotion 2.5%
• Generic brimonidine 0.2% ophthalmic solution
• Generic cyclobenzaprine 5mg, 10mg tablets
• Generic tizanidine 2mg, 4mg tablets
• Chlorzoxazone tab 500 mg

Initial criteria

• 1. The patient has an FDA labeled or Compendia approved indication for the requested agent AND
• 2. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• 3. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
• B. 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. 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
• B. The patient is currently being treated with the requested agent and is stable on the requested agent [chart notes required] OR
• C. The patient has tried and had an inadequate response to optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative [chart notes required] OR
• D. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to ONE more cost-effective, clinically appropriate, formulary alternative not expected to occur with the requested agent [chart notes required] OR
• F. The patient has an FDA labeled contraindication to ONE more cost-effective, clinically appropriate, formulary alternative not expected to occur with the requested agent [chart notes required] OR
• G. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative is expected to be ineffective based on known patient or drug characteristics; or cause a significant barrier to adherence; or worsen a comorbid condition; or decrease ability to maintain functional ability; or cause an adverse reaction or harm [chart notes required] OR
• H. Optimized therapy of ONE more cost-effective, clinically appropriate, formulary alternative is not in the best interest of the patient based on medical necessity [chart notes required] OR
• I. The patient has tried another prescription drug in the same pharmacologic class or mechanism of action and it was discontinued due to lack of efficacy or an adverse event [chart notes required]
• Compendia Allowed: AHFS, or DrugDex 1, 2a, or 2b level of evidence
• Length of Approval: 12 months
• Alternate Approval: for BCBS NM Fully Insured or NM HIM members meeting rare disease criteria or for Ohio Fully Insured/HIM Shop members meeting supportive criteria with FDA indication, compendia support, or peer-reviewed literature.

Reauthorization criteria

• 1. The patient was previously approved for the requested agent through the Prime Therapeutics Prior Authorization process in the previous 18 months

Approval duration

12 months