elagolix — Blue Cross Blue Shield of Montana

Initial criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• 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 OR 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective
• Accepted non-oncology compendia: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text must be supportive)
• Accepted oncology compendia: NCCN 1 or 2A, AHFS-DI (narrative text supportive), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (narrative text supportive), LexiDrugs evidence level A, peer-reviewed medical literature

Approval duration

12 months