440 Form

Pharmacy Medical Policy
Influenza Drugs

Table of Contents: Authorization Information
Coverage Criteria
Description
Appendix
Policy History
References

Policy Number: 440 BCBSA Reference Number: None

Prior Authorization Information

Policy ☐ Prior Authorization ☐ Step Therapy ☒ Quality Care Dosing ☐ Administrative Reviewing Department Pharmacy Operations: Tel: 1-800-366-7778 Fax: 1-800-583-6289 To request for coverage: Providers may call, fax, or mail the attached form (Formulary Exception/Prior Authorization form) to the address below.
Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043
Tel: 1-800-366-7778 Fax: 1-800-583-6289

Individual Consideration for the atypical patient: Policy for requests that do not meet clinical criteria of this policy, see section labeled Individual Consideration
Policy Last Updated 11/1/2025 Pharmacy (Rx) or Medical (MED) benefit coverage ☒ Rx ☒ MED Policy applies to Commercial members with BCBSMA formulary:
• Managed Care (HMO/POS) • PPO/EPO
• Indemnity
• MEDEX with Rx plans • Managed Blue for Seniors Policy does NOT apply to: • Medicare Advantage
See Appendix for additional information.

Please refer to the chart below for the formulary status of the medications affected by this policy.

Drug Formulary Status
(BCBSMA Commercial Plan) Special Considerations Oseltamivir

Covered, QCD

• Not available for mail service • May be covered at the highest copayment tier based on member’s benefit design at the retail pharmacy Tamiflu (oseltamivir) Relenza (zanamivir) Xofluza (baloxavir marboxil) QCD (Quality Care Dosing – refer to Policy 621b)
Length of Approval See below.

Coverage for these medications is for up to: TREATMENT OF INFLUENZA Oseltamivir, Tamiflu, Relenza a 5-day course of treatment PROPHYLAXIS OF INFLUENZA Oseltamivir, Tamiflu, Relenza a 10-day course of prophylaxis within 180 days Xofluza a one-day course of therapy within 180 days IF within 48 hours of the start of symptoms.
Coverage for additional supplies of these medications would need to be reviewed on an individual basis.

Description

This policy is reviewed on an annual basis in order to remain current with treatment guidelines and CDC recommendations. We do not cover the above drugs for other conditions not listed above.

According to the CDC, there are four FDA-approved antiviral medications used during the latest flu season:

Drug Name Age, per FDA Dose, Per FDA Oseltamivir phosphate (Tamiflu, available as generic) Treatment: 14 days and older Prophylaxis: 1 year and older Treatment: Twice daily x 5 days Prophylaxis: Once daily x10 days Zanamivir (Relenza) Not recommended for people with breathing problems like asthma or COPD. Treatment: 7 years and older Prophylaxis: 5 years and older Treatment: Twice daily x 5 days Prophylaxis: Once daily x10 days for household setting, 28 days for community outbreaks Baloxavir (Xofluza) Treatment: 5 years and older Prophylaxis: 5 years and older Single dose Peramivir (Rapivab) Excluded from the BCBSMA Pharmacy Benefit and out of scope for this medical policy Ages 5-11 who do not have any chronic medical conditions. Approved for all people 12 years and older.

Appendix Forms To request prior authorization using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm), click the link below: https://www.bluecrossma.org/medical- policies/sites/g/files/csphws2091/files/acquiadam- assets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf OR Print and fax, Massachusetts Standard Form for Medication Prior Authorization Requests #434 Individual Consideration (for Atypical Patients) Our medical policies are written for most people with a given condition. Each policy is based on peer reviewed clinical evidence. We also take into consideration the needs of atypical patient populations and diagnoses.
If the coverage criteria outlined is unlikely to be clinically effective for the prescribed purpose, the health care provider may request an exception to cover the requested medication based on an individual’s unique clinical circumstances. This is also referred to as “individual consideration” or an “exception request.”
Some reasons why you may need us to make an exception include: therapeutic contraindications; history of adverse effects; expected to be ineffective or likely to cause harm (physical, mental, or adverse reaction).
To facilitate a thorough and prompt review of an exception request, we encourage the provider to include additional supporting clinical documentation with their request. This may include: • Clinical notes or supporting clinical statements; • The name and strength of formulary alternatives tried and failed (if alternatives were tried) and specifics regarding the treatment failure, if applicable; • Clinical literature from reputable peer reviewed journals; • References from nationally recognized and approved drug compendia such as American Hospital Formulary Service® Drug Information (AHFS-DI), Lexi-Drug, Clinical Pharmacology, Micromedex or Drugdex®; and • References from consensus documents and/or nationally sanctioned guidelines

Providers may call, fax or mail relevant clinical information, including clinical references for individual patient consideration, to:

Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043 Phone: 1-800-366-7778 Fax: 1-800-583-6289

Policy History Date Action 11/2025 Annual Review: updated Description according to latest CDC recommendations. Updated to standardized Medical Policy format and references. 7/2023 Reformatted Policy. 11/2022 Updated note with Tamiflu age update. 11/2018 Updated to include Xofluza ™ and Oseltamivir. 6/2017 Updated address for Pharmacy Operations.

1/2014 Updated ExpressPAth Language and removed Blue Value. 4/2012 Reviewed 4/2012 MPG-Cardiology and Pulmonology, no changes in coverage were made. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 3/2010 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 11/2009 Updated to remove reimbursement request form, add standard exception form and clarify quantity information.
3/2009 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 10/2008 Updated to allow coverage for Tamiflu® and Relenza®.
3/2008 Reviewed 3/08 MPG- Pulmonology, Allergy and ENT/Otolaryngology, no changes in coverage were made. 3/2008 Updated to cover Tamiflu / Relenza at the highest tier copay level at retail pharmacy from 3/08/2008 - 5/31/0208 to address CDC recommendations of flu vaccine and Amantadin/Ramantidne ineffectiveness. 1/2008 Updated to remove reference to 06 flu season and to update FDA approved age ranges for Tamiflu®and Relenza®. 3/2007 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 1/7/200 New policy, effective 1/7/200, describing covered and non-covered indications.

References

1. Centers for Disease Control and Prevention. About Influenza Antiviral Medications. https://www.cdc.gov/flu/hcp/antivirals/index.html. Accessed August 8th, 2025.
2. Centers for Disease Control and Prevention. Treating Flu with Antiviral Drugs. https://www.cdc.gov/flu/treatment/antiviral-drugs.html. Accessed August 8, 2025.
3. FDATALK PAPER July 27, 1999 available at http://www.fda.gov/bbs/topics/ANSWERS/ANS00966.html
4. Findings of the FDA Antiviral Drugs Advisory Committee on Relenza® - Memorandum from Director of the Division on Antiviral Drugs of FDA, dated 7/26/99. Available at fda.gov/cder
5. Relenza [package insert], Research Triangle Park, NC: GlaxoSmithKline; 12/2010.
6. Revised safety labeling for Relenza (zanamivir) issued by Glaxo Wellcome INC. For additional information see the FDA website at: http://www.fda.gov/medwatch/safety/2000/relenz.htm.
7. See the CDC Recommendations against the Use of Amantadine and Rimantadine for the Treatment or Prophylaxis of Influenza in the United States during the 2005-2006 Influenza Season. Available at: http://www.cdc.gov/flu/han011406.htm
8. See the CDC’s MMWR December 17, 1999 / 48(RR14);1-9 Neuraminidase Inhibitors for Treatment of Influenza A and B Infections www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4814a1.htm
9. Tamilfu [package insert]. Nutley, NJ: Roche Pharmaceuticals; 12/2012.
10. Tamiflu - Memo from the FDA Director, Division of Antiviral Drugs, dated October 25, 1999 at www.fda.gov/cder/drug/infopage/tamiflu/directormemo.htm
11. Xofluza [package insert], Settsu, Japan: Shionogi & Co., Ltd.; 5/2025.