Xolremdi — Blue Cross Blue Shield of Illinois

other FDA labeled or compendia-supported indication for Ohio Fully Insured or HIM Shop members

Initial criteria

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

Same as renewal criteria above for the requested agent: continued benefit, prior approval, no contraindications, not used with CXCR4 antagonist, prescriber specialist involvement

12 months