Prior authorization requirements for Lucemyra (lofexidine)
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Form and clinical criteria governing prior authorization requests for Lucemyra (lofexidine) for members served by Anthem Blue Cross and Blue Shield programs in Indiana; applies to prescribing providers submitting PA for covered plans listed on the form.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met:
Confirmation of prior trial can be by claims history or submitted chart documentation.
The policy covers LUCEMYRA (lofexidine) only when the prior authorization form criteria are met. In addition to the required prior trial/step-therapy and quantity rules, requests must conform to the plan's supply-interval limits and any documentation requirements on the form. Specifically, the requested claim must fall within the plan limitation of an initial 7-day supply with a subsequent 7-day supply (total 14 days) every 180 days, and confirmation of prior therapy must be provided by claims history or submitted chart documentation when applicable.
Requests that exceed the form’s stated maximum daily tablets or the plan supply limitation require explicit medical justification on the form. The form asks whether the requested quantity does not exceed 16 tablets (2.88 mg) per day and whether the claim is within the plan maximum of a seven-day supply with a subsequent seven-day supply (total 14 days) every 180 days. If either answer is “No,” the provider must supply clinical rationale for continued or greater use; without that documentation the request is not supported by the form.
Coding & Limits
Provider Actions & Submission
Prior authorization required with prior-trial and quantity/supply attestations
Prior authorization is required for LUCEMYRA (lofexidine). The request must document a prior trial and failure of a guideline-accepted alpha-2 adrenergic agonist and attest that the requested daily quantity does not exceed 16 tablets (2.88 mg) and conforms to the plan's 7-day supply limitation with a possible subsequent 7-day supply (total 14 days every 180 days).
Step therapy: prior trial or medical justification required
Provider must document trial and failure of another guideline-accepted alpha-2 adrenergic agonist agent or supply medical justification explaining why Lucemyra is preferred over other alpha-2 adrenergic agonists.
Document prior trial with claims history or chart documentation
When prior therapy is claimed, confirmation of the previous trial must be provided by claims history or submitted chart documentation.
- If prior trial is indicated, list the name(s) and dose(s) of the previous alpha-2 adrenergic agent(s) trialed on the form.
Submit completed form via fax to designated PA center numbers
Complete the PA form in its entirety and fax it to the Prior Authorization of Benefits Center at 844-864-7860 for retail or 888-209-7838 for medical injectable requests.
- Ensure the prescribing provider completes all sections; include prescriber signature and return fax/phone as requested.
- Submit retroactive PA requests separately when dates of service are more than 30 calendar days prior to submission, per form instructions.
Incomplete or missing form sections will cause request return
The request will be returned if the form is not completed in its entirety or if required sections are missing; the prescribing provider must complete all sections.
- Mark retroactive PA box and provide dates of service when applicable; omissions related to retroactive submission instructions may cause return of the request.
Background
Lucemyra (lofexidine) is an alpha-2 adrenergic agonist used in the management of opioid withdrawal symptoms. The prior authorization form requires documentation of a previous trial and failure of a guideline-accepted alpha-2 adrenergic agonist (with name and dose recorded) or a written medical justification for use over other alpha-2 agents; confirmation of prior trial may be provided by claims history or submitted chart documentation.
Definitions
Initial Therapy Criteria
Initial therapy — Initial authorization requirements
Initial authorization requirements
If no prior trial, medical justification must be provided on the form.
Attest on the form that requested daily quantity does not exceed 16 tablets.
If requesting continued use beyond 14 days per 180 days, provide medical rationale on the form.
Continuation Therapy Criteria
Continuation therapy limits
Limits on continuation
Provider must supply clinical rationale on the form if requesting continued use beyond plan limits.
Step Therapy Requirements
| Step | Requirement | Provider action / documentation |
|---|---|---|
| 1 | ||
| Document prior trial and failure of a guideline-accepted alpha-2 adrenergic agonist OR provide medical justification to use Lucemyra instead | ||
| Indicate prior agent name(s) and dose(s) on the form and supply confirmation of prior trial via claims history or submitted chart documentation; if no prior trial, provide medical justification on the form. |
Quantity Limits
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