mavacamten — Blue Cross Blue Shield of Illinois
Other FDA-labeled or compendia-supported indications (Ohio members only, Fully Insured or HIM Shop plans)
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA-labeled contraindications to the requested agent
- 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 for the requested agent and route OR (3) Prescriber submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective—case studies not acceptable
- Accepted study or compendia evidence: DrugDex level 1, 2A, 2B; AHFS-DI supportive narrative; NCCN 1 or 2A; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; other peer-reviewed medical literature
Approval duration
12 months