givinostat hcl — Blue Cross Blue Shield of Illinois

Initial criteria

• The member resides in Ohio
• 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: (a) The patient has another FDA labeled indication for the requested agent and route of administration OR (b) The patient has another indication supported in compendia (Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI supportive narrative; Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI supportive narrative, DrugDex level 1, 2A, or 2B, Clinical Pharmacology supportive narrative, LexiDrugs evidence level A, peer-reviewed medical literature) OR (c) The prescriber has submitted TWO peer-reviewed journal articles supporting the use as generally safe and effective (acceptable designs: randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

Approval duration

12 months