Hympavzi — Blue Cross Blue Shield of Illinois

Initial criteria

• Request for BCBS MT Fully Insured or MT HIM member: patient age <18 years; no FDA labeled contraindications; indication supported in TWO articles from major peer-reviewed journals as generally safe and effective; and age support shown for patient’s age bracket in TWO articles
• Request for BCBS NM Fully Insured or NM HIM member: no FDA labeled contraindications; requested indication is a rare disease; and ONE of the following: (1) patient has another FDA labeled indication for the requested agent and route OR (2) indication supported in compendia for the requested agent and route OR (3) all of the following for Ohio: (A) member resides in Ohio AND (B) plan is Fully Insured or HIM Shop AND (C) no FDA labeled contraindications AND (D) one of the following: (a) FDA indication, (b) compendia-supported indication, or (c) two peer-reviewed journal articles supporting use as generally safe and effective

Approval duration

BCBSOK: 36 months; All other plans: 12 months