palovarotene — Blue Cross Blue Shield of Illinois

other FDA labeled or compendia-supported indications (Ohio, Fully Insured or HIM Shop plans)

Initial criteria

1. The member resides in Ohio AND
2. 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 supporting the proposed use(s) as generally safe and effective (case studies not acceptable)

12 months