Xerese — Blue Cross Blue Shield of Texas

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: The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR 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 currently stable on it [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 or 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, cause a significant barrier, worsen a comorbid condition, decrease ability to perform daily activities, or cause 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 in same class or mechanism as optimized therapy of a more cost-effective, clinically appropriate, formulary alternative and it was discontinued due to lack of efficacy or adverse event [chart notes required]
• Additional approval path: For BCBS NM Fully Insured or NM HIM member: No FDA labeled contraindications AND requested indication is a rare disease AND (patient has another FDA labeled or compendia indication for same agent and route) OR For Ohio Fully Insured or HIM Shop members: No FDA labeled contraindications AND member resides in Ohio AND (patient has another FDA labeled or compendia indication OR prescriber submitted two peer-reviewed journal articles showing proposed use is safe and effective).
• Compendia allowed: AHFS, DrugDex level 1, 2A, or 2B (non-oncology); NCCN 1 or 2A (oncology), AHFS-DI narrative, DrugDex 1, 2A, 2B, Clinical Pharmacology narrative, Lexi-Drugs evidence level A, peer-reviewed medical 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