Xhance — Blue Cross Blue Shield of Texas

Initial criteria

• 1. ONE of the following: A. The patient has a diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP) OR B. The patient has a diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) OR C. The patient has another FDA labeled indication for the requested agent and route of administration OR D. The patient has another indication that is supported in compendia for the requested agent and route of administration
• 2. If the patient has an FDA labeled 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 for using the requested agent for the patient’s age for the requested indication
• 3. ONE of the following: A. The prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent [chart notes required] OR B. The patient has tried and had an inadequate response to ONE generic OR OTC intranasal corticosteroid [chart notes required] OR C. ONE generic OR OTC intranasal corticosteroid was discontinued due to lack of efficacy or adverse event [chart notes required] OR D. The patient has intolerance or hypersensitivity to ONE generic OR OTC intranasal corticosteroid not expected with requested agent [chart notes required] OR E. The patient has an FDA labeled contraindication to ALL generic AND OTC intranasal corticosteroids not expected with requested agent [chart notes required] OR F. ONE generic OR OTC intranasal corticosteroid is expected to be ineffective or inappropriate based on patient clinical characteristics, adherence, comorbidity, or functional impairment, or may cause harm [chart notes required] OR G. ONE generic OR OTC intranasal corticosteroid is not in the best interest of the patient based on medical necessity [chart notes required] OR H. The patient has tried another prescription drug in the same pharmacologic class or mechanism and discontinued due to lack of efficacy or adverse event [chart notes required]
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia allowed: AHFS or DrugDex level 1, 2a, or 2b evidence
• ALTERNATE approval: for BCBS NM Fully Insured or NM HIM member when: A. No FDA labeled contraindication AND B. Indication is a rare disease AND C. One of: (1) other FDA labeled indication OR (2) other compendia supported indication
• ALTERNATE approval: for member residing in Ohio, with Fully Insured or HIM Shop plan, when: A. No FDA labeled contraindication AND B. one of: (1) other FDA labeled indication OR (2) other compendia supported indication OR (3) prescriber submits TWO peer-reviewed journal articles supporting proposed use

Reauthorization criteria

• 1. The patient has been previously approved through the plan’s prior authorization process
• 2. The patient has had clinical benefit with the requested agent
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months