Rytary — Blue Cross Blue Shield of Texas

Preferred products

• Generic carbidopa-levodopa ER

Initial criteria

• The patient has an FDA approved indication for the requested agent AND
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• ONE of the following:
• A. The patient has stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR used to treat an associated condition related to stage four advanced, metastatic cancer [chart notes required] AND the use is consistent with best practices for treatment of such cancer and supported by peer-reviewed, evidence-based literature and FDA labeling OR
• B. The patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
• C. The patient has tried and had an inadequate response to optimized therapy of a more cost-effective, clinically appropriate, formulary alternative (generic carbidopa-levodopa ER) [chart notes required] OR
• D. Optimized therapy of a more cost-effective, clinically appropriate, formulary alternative was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to a more cost-effective, clinically appropriate, formulary alternative that is not expected to occur with the requested agent [chart notes required] OR
• F. The patient has an FDA labeled contraindication to a more cost-effective, clinically appropriate, formulary alternative that is not expected to occur with the requested agent [chart notes required] OR
• G. Optimized therapy of a more cost-effective, clinically appropriate, formulary alternative 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 adherence; or worsen a comorbid condition; or decrease the patient's ability to perform daily activities; or cause harm [chart notes required] OR
• H. Optimized therapy of a 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 drug in the same pharmacologic class or mechanism as optimized therapy of the more cost-effective alternative and discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]

Reauthorization criteria

• 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