Diclegis — Blue Cross Blue Shield of Illinois
other FDA labeled indication or compendia supported use for requested agent and route of administration
Initial criteria
- For BCBS NM Fully Insured or NM HIM member: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease AND (C) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route OR (2) The patient has another indication supported in compendia for the requested agent and route
- For members residing in Ohio with Fully Insured or HIM Shop (SG) plan: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route OR (2) The patient has another indication supported in compendia for the requested agent and route OR (3) The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s)
Approval duration
12 months