Agamree — Blue Cross Blue Shield of Illinois

off-label indications supported by peer-reviewed literature

Initial criteria

1. Member resides in Ohio.
2. Plan is Fully Insured or HIM Shop (SG).
3. The patient does not have FDA labeled contraindications to the requested agent.
4. ONE of the following applies: (a) The patient has another FDA labeled indication for the requested agent and route of administration OR (b) The patient has another indication supported in compendia (DrugDex level 1, 2A, or 2B; AHFS-DI supportive) OR (c) The prescriber submitted two peer-reviewed major journal articles supporting the proposed off-label use.

12 months (all plans except BCBSOK 36 months)