fecal microbiota spores, live-brpk caps — Blue Cross Blue Shield of Illinois
Off-label use for members under BCBS MT, NM, or OH plans as described
Initial criteria
- For BCBS MT Fully Insured or MT HIM members: (A) Patient age < 18 years; (B) Patient has no FDA‑labeled contraindications; (C) Indication supported in TWO articles from major peer‑reviewed medical journals (e.g., JAMA, NEJM, Lancet) showing general safety and efficacy; (D) Age bracket supported in TWO articles from major peer‑reviewed medical journals showing general safety and efficacy (infancy, childhood, adolescence as defined)
- For BCBS NM Fully Insured or NM HIM members: (A) Patient has no FDA‑labeled contraindications; (B) Requested indication is a rare disease; (C) ONE of the following: (1) Patient has another FDA‑labeled indication for requested agent and route of administration; OR (2) Requested indication supported in compendia for requested agent and route of administration
- For Ohio Fully Insured or HIM Shop (SG) members: (A) Member resides in Ohio; (B) Plan is Fully Insured or HIM Shop (SG); (C) Patient has no FDA‑labeled contraindications; (D) ONE of the following: (1) Patient has another FDA‑labeled indication for requested agent and route of administration; OR (2) Requested indication supported in compendia; OR (3) Prescriber submitted TWO peer‑reviewed medical journal articles supporting safety and efficacy
Approval duration
12 months (one course per 12 months)