birch triterpenes gel 10% — Blue Cross Blue Shield of Montana

Initial criteria

• Applicable to BCBS NM Fully Insured or NM HIM members when ALL of the following are met: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease 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 that is supported in compendia for the requested agent and route of administration
• Alternatively, for Ohio residents with Fully Insured or HIM Shop (SG) plans, 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 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 articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective (case studies not acceptable)

Approval duration

12 months