asfotase alfa — Blue Cross Blue Shield of Illinois

Initial criteria

• Member resides in Ohio
• Plan type is Fully Insured OR HIM Shop (Small Group)
• No FDA-labeled contraindications to requested agent
• ONE of the following: (1) Patient has another FDA-labeled indication for requested agent and route of administration OR (2) Patient has another indication supported in compendia (DrugDex level 1, 2A or 2B; AHFS-DI supportive narrative) for requested agent and route OR (3) Prescriber submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective, with acceptable study designs (randomized, double-blind, placebo-controlled). Case studies not accepted.

Approval duration

12 months