furosemide subcutaneous cartridge kit — Blue Cross Blue Shield of Illinois

Initial criteria

• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• The requested indication is a rare disease AND 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 that is supported in compendia for the requested agent and route of administration OR
• For Ohio members: ALL of the following:
• A. The member resides in Ohio AND
• B. The plan is Fully Insured or HIM Shop (SG) AND
• C. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• D. 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 that is supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective

Reauthorization criteria

• Same as initial criteria

Approval duration

12 months