Rayos — Blue Cross Blue Shield of Illinois

Initial criteria

• Member resides in Ohio AND 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:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed medical journals (e.g., JAMA, NEJM, Lancet) supporting proposed use(s) as generally safe and effective; accepted study designs may include randomized, double-blind, placebo-controlled clinical trials (case studies not acceptable)
• Non-oncology compendia allowed: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative text
• Oncology compendia allowed: NCCN 1 or 2A; AHFS-DI supportive narrative; DrugDex level 1, 2A, or 2B; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; or peer-reviewed medical literature

Approval duration

12 months