doxepin hydrochloride cream 5% — Blue Cross Blue Shield of Montana
rare disease indications (BCBS NM Fully Insured or NM HIM members)
Initial criteria
- For BCBS NM Fully Insured or NM HIM members: ALL of the following: (A) patient has no FDA labeled contraindications AND (B) requested indication is a rare disease AND (C) ONE of the following: (1) patient has another FDA labeled indication and route of administration OR (2) patient has another compendia supported indication for the requested agent and route of administration
- For Ohio Fully Insured or HIM Shop members: ALL of the following: (A) member resides in Ohio AND (B) plan is Fully Insured or HIM Shop (SG) AND (C) patient has no FDA labeled contraindications AND (D) ONE of the following: (1) another FDA labeled indication for the agent and route OR (2) another indication supported in compendia OR (3) prescriber submitted TWO peer-reviewed journal articles supporting proposed use
Reauthorization criteria
- Same as initial; continued need and no contraindications
Approval duration
12 months