requested agent (Ohio members) — Blue Cross Blue Shield of Illinois
any FDA labeled indication or compendia or literature supported indication (Ohio fully insured/HIM Shop)
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does not have FDA labeled contraindications
- Patient has FDA labeled indication OR compendia supported indication OR two peer-reviewed journal articles supporting proposed use
Approval duration
12 months