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Combination NSAIDs - Net Results Formulary
Restricted Product(s):
- Consensi® (celecoxib / amlodipine)
FDA Approved Use:
- For patients for whom treatment with amlodipine for hypertension and celecoxib for osteoarthritis are appropriate.
Criteria for Approval of Restricted Product(s):
1. The patient is 18 years of age or older; AND
2. The patient is using the medication to treat hypertension; AND
3. The patient is using the medication to treat osteoarthritis; AND
4. The provider has given a written statement as to why the patient is unable to utilize the individual components (either over-the-counter or prescription) of this combination medication, including a valid explanation of the undue risk this would result in for the patient’s health [medical record documentation required]; AND
5. For products that require Value PA, refer to the Vaue PA UM Criteria.
Duration of Approval: 180 days (6 months)
References:
all information referenced is from FDA package insert unless otherwise noted below.
Lanza FL, et al. Members of the Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 2009; 104:728 – 738; doi: 10.1038/ajg.2009.115; published online 24 February 2009.
Policy Implementation / Update Information:
Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.
October 2024: Criteria change (Ubrelvy, Nurtec ODT, Zavzpret): Added requirement that acute use CGRPs will not be taken concomitantly with another acute migraine therapy.
August 2024: Criteria update: Updated definition of episodic migraine to be ≥ 4 migraine headache days per month.
April 2024: Criteria change: Created an Essential only policy. Updated Nurtec QL for episodic migraine.
January 2024: Criteria change: Added the option for use of a botulinum toxin agent in combination with a CGRP receptor antagonist for patients continuing to experience 4 or more migraine headache days per month after treatment with either a 3-month trial of a CGRP receptor antagonist or a 6-month trial (2 injection cycles) of Botox. References added.
October 2023: Criteria update: Removed allowance of Botox in the last 3 months due to inability to see provider during COVID-19 pandemic. June 2023: Criteria update: Added new to market Zavzpret to policy.
May 2023: Criteria change (Qulipta): Expanded indication for Qulipta to include the preventative treatment of chronic migraine in adults.
March 2023: Criteria update: Added definitions for chronic and episodic migraine. No change to criteria intent.
July 2022: Criteria update: Any authorization for a botulinum toxin agent used for the same indication as the requested agent will be terminated.
January 2022: Criteria change: Reduced step requirement through a single triptan product for acute migraine use. Step through Emgality and Aimovig removed for Ajovy requests. Historical policy changes prior to 2022 can be obtained from BCBSNC Corporate Pharmacy
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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