Empaveli (pegcetacoplan) — Blue Cross Blue Shield of Illinois

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• Patient does NOT have any FDA labeled contraindications to Empaveli
• 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 (non-oncology: DrugDex level 1, 2A, or 2B; AHFS-DI supportive; 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 supportive) OR (3) prescriber submitted TWO articles from major peer-reviewed medical journals supporting the proposed use as safe and effective (acceptable designs include randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

Approval duration

12 months