trofinetide oral soln 200 MG/ML — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. Member resides in Ohio AND
• 2. Plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• A. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. ONE of the following:
• 1. Patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. Patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective

Approval duration

12 months