Oxervate — Blue Cross Blue Shield of Illinois

off-label use for BCBS MT members age <18 years

Initial criteria

For BCBS MT Fully Insured or MT HIM members under age 18:
Patient <18 years old
No FDA labeled contraindications
Indication supported in TWO peer-reviewed journal articles as generally safe and effective (acceptable designs: randomized, double blind, placebo controlled clinical trials; excludes case studies)
Age bracket supported by evidence in TWO peer-reviewed journal articles as generally safe and effective
OR For Ohio fully insured or HIM Shop (SG) members:
Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
No FDA labeled contraindications
ONE of the following:
1. Another FDA labeled indication for the requested agent/route OR
2. Indication supported in compendia for the requested agent/route OR
3. Prescriber submitted TWO peer-reviewed articles supporting proposed use as generally safe and effective (acceptable study designs noted)
Acceptable compendia references:
Non-oncology: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative
Oncology: NCCN 1 or 2A; AHFS-DI supportive narrative; DrugDex 1, 2A, or 2B; Clinical Pharmacology supportive narrative; LexiDrugs level A; peer-reviewed medical literature

12 months