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Tetracycline Hydrochloride — Blue Cross Blue Shield of Texas

FDA labeled indications including acne, rosacea, tick-borne disease, other labeled or compendia-supported uses

Preferred products

  • doxycycline monohydrate capsule
  • doxycycline monohydrate tablet
  • doxycycline hyclate tablet
  • doxycycline hyclate capsule
  • doxycycline hyclate monohydrate suspension
  • tetracycline hcl capsule

Initial criteria

  • ONE of the following: (A) The prescriber states the patient has been treated with the requested agent (not including samples) within the past 90 days AND is at risk if therapy is changed OR (B) ALL of the following conditions:
  • 1. ONE of the following: (A) The requested agent is being used off-label for the treatment of a tick-borne disease OR (B) BOTH of the following: (1) The patient has an FDA labeled indication for the requested agent and route of administration AND (2) If the patient has an FDA approved indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support of using the requested agent for the patient’s age for the requested indication.
  • 2. ONE of the following depending on agent category:
  • A. For doxycycline agents or Seysara: ONE of the following: (1) The patient has stage 4 advanced, metastatic cancer and the requested agent is being used for the cancer or associated condition AND the use is consistent with FDA and evidence-based best practices OR (2) The patient has had ≥1 prerequisite agent tried and failed, discontinued due to adverse event, intolerance, inefficacy, or is otherwise inappropriate/contraindicated based on chart notes and medical necessity within the past 90 days.
  • B. For minocycline or tetracycline agents: ONE of the following: (1) Stage 4 advanced, metastatic cancer as above OR (2) The patient has tried and failed or discontinued ≥1 prerequisite agent within the past 180 days or any of the following apply to a prerequisite agent: intolerance, hypersensitivity, expected ineffectiveness, adverse reaction risk, non–best interest, or FDA labeled contraindication.
  • 3. If the patient has a diagnosis of acne: ONE of the following: (A) The patient will use a benzoyl peroxide agent OR a retinoid agent in combination with the requested agent OR (B) The patient has intolerance, hypersensitivity, or FDA labeled contraindication to a benzoyl peroxide agent OR a retinoid agent.
  • 4. If the patient has acne or rosacea, the patient will NOT use the requested agent concurrently with another tetracycline derivative for acne or rosacea.
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent.

Reauthorization criteria

  • Member continues to meet initial criteria OR demonstrates ongoing medical necessity, continued benefit from therapy, and absence of contraindications.

Approval duration

BCBSOK 36 months; others 12 months