alpelisib (PROS) — Blue Cross Blue Shield of Illinois

off-label or other uses (Fully Insured or HIM Shop Ohio members)

Initial criteria

ALL of the following:
1. Member resides in Ohio AND
2. Plan is Fully Insured or HIM Shop (SG) AND BOTH of:
A. Patient does NOT have any FDA labeled contraindications to the requested agent AND
B. ONE of the following:
1. Patient has another FDA labeled indication for the requested agent and route of administration OR
2. Patient has another indication supported in compendia for the requested agent and route of administration OR
3. Prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective [case studies not acceptable]
Compendia accepted:
Non-oncology: DrugDex level 1, 2A, or 2B; AHFS-DI (supportive narrative)
Oncology: NCCN 1 or 2A; AHFS-DI (supportive narrative); DrugDex level 1, 2A, or 2B; Clinical Pharmacology (supportive narrative); LexiDrugs level A; peer-reviewed medical literature

12 months