Nuplazid — Blue Cross Blue Shield of Illinois

member resides in Ohio

Initial criteria

The member resides in Ohio AND
The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
B. 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. Accepted study designs may include randomized, double blind, placebo controlled clinical trials. Case studies are not acceptable.
Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text must be supportive)
Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative text must be supportive), DrugDex level 1, 2A, or 2B, or Clinical Pharmacology (narrative text must be supportive), LexiDrugs evidence level A, peer-reviewed medical literature

12 months