Qudexy xr — Blue Cross Blue Shield of Texas

migraine

Initial criteria

ONE of the following: (A) patient has a diagnosis of migraine OR (B) ONE of the following: (1) patient has ONE of the following diagnoses: partial onset seizures OR primary generalized tonic-clonic seizures OR Lennox-Gastaut Syndrome OR (2) patient has a medication history of use of an anti-seizure medication that is not topiramate OR (C) patient has another FDA labeled indication for the requested agent and route of administration OR (D) patient has another indication supported in compendia for the requested agent and route of administration
AND if patient has an FDA labeled indication, then ONE of the following: (A) patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) there is support for using the requested agent for the patient’s age for the requested indication
AND patient does NOT have any FDA labeled contraindications to the requested agent
For BCBS NM Fully Insured or NM HIM member: the patient has no contraindications, the requested indication is a rare disease, and ONE accepted indication or compendia support criteria are met; OR for Ohio Fully Insured or HIM Shop member, similar criteria apply and prescriber may supply two peer-reviewed medical journal articles supporting proposed use

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND ONE of the following: (A) patient has had clinical benefit with the requested agent OR (B) patient has a medication history of use of an anti-seizure medication that is not topiramate
AND patient does NOT have any FDA labeled contraindications to the requested agent

12 months