sirolimus gel — Blue Cross Blue Shield of Illinois

other FDA labeled or compendia-supported indication (Ohio residency and fully insured or HIM Shop plan)

Initial criteria

Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
ONE of the following applies: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO articles from peer‑reviewed professional medical journals supporting the proposed use as safe and effective (acceptable study designs include randomized, double‑blind, placebo‑controlled clinical trials; case studies not accepted)
For non-oncology uses, acceptable compendia: DrugDex level 1, 2A, or 2B, or AHFS‑DI (narrative text supportive)
For oncology uses, acceptable compendia: NCCN 1 or 2A, AHFS‑DI (narrative supportive), DrugDex level 1, 2A, 2B, Clinical Pharmacology (narrative supportive), LexiDrugs evidence level A, or peer‑reviewed medical literature

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist) or has consulted with such a specialist
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months