Ctexli — Blue Cross Blue Shield of Illinois
other FDA labeled indication or compendia supported indication (Ohio members; Fully Insured or HIM Shop plans)
Initial criteria
- The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
- The patient does NOT have any FDA labeled contraindications to the requested agent
- ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia (Non-oncology: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative; Oncology: NCCN 1 or 2A, AHFS-DI supportive, DrugDex level 1, 2A, or 2B, Clinical Pharmacology supportive, LexiDrugs evidence level A, peer-reviewed medical literature) OR (3) The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective (case studies not acceptable)
Approval duration
12 months