This program applies to Commercial, Blue Partner, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace.
POLICY REVIEW CYCLE
|
Effective Date
|
Date of Origin
|
|
04-01-2024
|
|
FDA APPROVED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
|
Target Brand Agent Name(s)
|
Target Generic Agent Name(s)
|
Strength
|
QL Amount
|
Dose Form
|
Day Supply
|
Duration
|
Addtl QL Info
|
Allowed Exceptions
|
Targeted NDCs When Exclusions Exist
|
|
|
|
|
Butalbital-Acetaminophen Cap 50-300 MG
|
50-300 MG
|
180
|
Capsules
|
30
|
DAYS
|
|
|
|
|
|
Butalbital-Aspirin-Caffeine Cap 50-325-40 MG
|
50-325-40 MG
|
180
|
Capsules
|
30
|
DAYS
|
|
|
|
|
Allzital
|
Butalbital-Acetaminophen Tab 25-325 MG
|
25 MG ; 25-325 MG
|
360
|
Tablets
|
30
|
DAYS
|
|
|
|
|
Bac ; Esgic
|
Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG
|
50-325-40 MG
|
180
|
Tablets
|
30
|
DAYS
|
|
|
|
|
Bupap
|
Butalbital-Acetaminophen Tab 50-300 MG
|
50-300 MG
|
180
|
Tablets
|
30
|
DAYS
|
|
|
|
|
Esgic ; Zebutal
|
Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG
|
50-325-40 MG
|
180
|
Capsules
|
30
|
DAYS
|
|
|
|
|
Fioricet
|
Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG
|
50-300-40 MG
|
180
|
Capsules
|
30
|
DAYS
|
|
|
|
|
Tencon
|
Butalbital-Acetaminophen Tab 50-325 MG
|
50-325 MG
|
180
|
Tablets
|
30
|
DAYS
|
|
|
|
|
Vtol lq
|
Butalbital-Acetaminophen-Caffeine Soln 50-325-40 MG/15ML
|
50-325-40 MG/15ML
|
2700
|
mLs
|
30
|
DAYS
|
|
|
|
CLIENT SUMMARY – QUANTITY LIMITS
|
Target Brand Agent Name(s)
|
Target Generic Agent Name(s)
|
Strength
|
Client Formulary
|
|
|
Butalbital-Acetaminophen Cap 50-300 MG
|
50-300 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
|
Butalbital-Aspirin-Caffeine Cap 50-325-40 MG
|
50-325-40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Allzital
|
Butalbital-Acetaminophen Tab 25-325 MG
|
25 MG ; 25-325 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Bac ; Esgic
|
Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG
|
50-325-40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Bupap
|
Butalbital-Acetaminophen Tab 50-300 MG
|
50-300 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Esgic ; Zebutal
|
Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG
|
50-325-40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Fioricet
|
Butalbital-Acetaminophen-Caffeine Cap 50-300-40 MG
|
50-300-40 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Tencon
|
Butalbital-Acetaminophen Tab 50-325 MG
|
50-325 MG
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
|
Vtol lq
|
Butalbital-Acetaminophen-Caffeine Soln 50-325-40 MG/15ML
|
50-325-40 MG/15ML
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
|
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module
|
Clinical Criteria for Approval
|
|
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
- The requested quantity (dose) does NOT exceed the program quantity limit OR
- The requested quantity (dose) exceeds the program quantity limit AND BOTH of the following:
- ONE of the following:
- BOTH of the following:
- The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
- Information has been provided to support therapy with a higher dose for the requested indication OR
- BOTH of the following:
- The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
- Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
- BOTH of the following:
- The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
- Information has been provided to support therapy with a higher dose for the requested indication AND
- If the requested agent contains acetaminophen, the daily dose of acetaminophen does NOT exceed over 4 grams per 24 hours
Length of Approval: Approval duration is 1 month for dose titration requests and up to 6 months for all other requests
|
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ PS _ Pain_Medications_QL _ProgSum_ 04-01-2024
|
