Sporanox (itraconazole) — Blue Cross Blue Shield of Illinois

other compendia-supported or FDA labeled indications for Ohio Fully Insured or HIM Shop (SG) members

Initial criteria

For BCBS NM Fully Insured or NM HIM member, ALL of the following:
A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
B. The requested indication is a rare disease AND
C. ONE of the following:
1. The patient has another FDA labeled indication for the requested agent and route of administration OR
2. The patient has another indication that is supported in compendia for the requested agent and route of administration;
OR
For Ohio Fully Insured or HIM Shop (SG) member, ALL of the following:
A. The member resides in Ohio AND
B. The plan is Fully Insured or HIM Shop (SG) AND
C. The patient does NOT have any FDA labeled contraindications to the requested agent AND
D. ONE of the following:
1. The patient has another FDA labeled indication for the requested agent and route of administration OR
2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
3. The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective (e.g., randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

12 months