sparsentan — Blue Cross Blue Shield of Illinois

Initial criteria

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

Approval duration

12 months