All weight loss agents (Target Agents) — Blue Cross Blue Shield of Illinois

off-label or other indication approved criteria (Ohio fully insured or HIM Shop plans)

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
No FDA labeled contraindications to requested agent
ONE of:
(i) Patient has another FDA-labeled indication for the requested agent and route of administration OR
(ii) Patient has another indication supported in compendia (DrugDex 1,2A,2B; AHFS-DI narrative supportive; NCCN 1,2A; Clinical Pharmacology; LexiDrugs A) OR
(iii) Prescriber has submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective (randomized, double blind, placebo controlled clinical trials acceptable; case studies not accepted)

12 months