mitapivat sulfate — Blue Cross Blue Shield of Illinois

Initial criteria

• The member resides in Ohio AND
• The plan is Fully Insured or HIM Shop (SG) AND
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• 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 that is supported in compendia for the requested agent and route of administration OR C. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (journal articles required)
• Non-oncology compendia allowed: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative
• Oncology compendia allowed: NCCN 1 or 2A; AHFS-DI supportive; DrugDex level 1, 2A, or 2B; Clinical Pharmacology supportive; LexiDrugs evidence level A; peer-reviewed medical literature

Approval duration

36 months (BCBSOK); 12 months (All other plans)