requested agent (pediatric/peer-reviewed indication approval) — Blue Cross Blue Shield of Illinois
BCBS MT Fully Insured or MT HIM member under age 18
Initial criteria
- A. age < 18 years
- B. No FDA labeled contraindications to the requested agent
- C. Indication supported in TWO major peer-reviewed medical journal articles as generally safe and effective; accepted study designs include randomized, double blind, placebo controlled clinical trials; case studies not acceptable [journal articles required]
- D. Age bracket supported in TWO major peer-reviewed medical journal articles as generally safe and effective for infancy (birth < 2 years), childhood (2–11 years), or adolescence (12–17 years) [journal articles required]
Approval duration
12 months