ciclopirox — Blue Cross Blue Shield of Montana

Initial criteria

• 1. Request is for a BCBS NM Fully Insured or NM HIM member AND
• A. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. Requested indication is a rare disease AND
• C. ONE of the following:
• 1. Has another FDA labeled indication for the requested agent and route of administration OR
• 2. Has another compendia-supported indication for the requested agent and route of administration
• OR
• 2. ALL of the following:
• A. Member resides in Ohio AND
• B. Plan is Fully Insured or HIM Shop (SG) AND
• C. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• D. ONE of the following:
• 1. Has another FDA labeled indication for the requested agent and route of administration OR
• 2. Has another compendia-supported indication for the requested agent and route of administration

Approval duration

12 months