dextromethorphan hbr-quinidine sulfate — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis of pseudobulbar affect (PBA) AND one of the following: amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), dementia, stroke, or traumatic brain injury
• Prescriber has assessed the patient's PBA episodes (laughing and/or crying) prior to therapy
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist) or has consulted with such a specialist
• Patient does not have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s prior authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist) or has consulted with such a specialist
• Patient does not have any FDA-labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL); 3 months (other plans initial); 12 months renewal