requested agent (Factor IX) — Blue Cross Blue Shield of Illinois

rare disease or alternate indication (BCBSNM Fully Insured/HIM or Ohio Fully Insured/HIM Shop plans)

Initial criteria

For BCBS NM Fully Insured or NM HIM member: patient has no FDA-labeled contraindications AND requested indication is a rare disease AND ONE of: patient has another FDA-labeled indication and route OR patient has another indication supported in compendia
OR ALL of: member resides in Ohio AND plan is Fully Insured or HIM Shop AND patient has no FDA-labeled contraindications AND ONE of: patient has another FDA-labeled indication and route OR patient has another indication supported in compendia OR prescriber submitted two peer-reviewed journal articles supporting proposed use as safe/effective

12 months