Vanrafia — Blue Cross Blue Shield of Illinois

Initial criteria

• Member resides in Ohio AND
• Plan is Fully Insured or HIM Shop (SG) AND
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• 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 supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO peer-reviewed articles supporting proposed use as generally safe and effective (acceptable designs: randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

Approval duration

12 months