Emflaza — Blue Cross Blue Shield of Montana

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of: patient has another FDA labeled indication for the requested agent and route of administration OR another indication supported in compendia for requested agent and route OR prescriber submitted two peer-reviewed journal articles supporting safe and effective use (acceptable designs: randomized, double-blind, placebo-controlled; case studies not acceptable)
• Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (supportive text); Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (supportive text), DrugDex 1, 2A, 2B, Clinical Pharmacology (supportive text), LexiDrugs Evidence Level A, peer-reviewed literature

Approval duration

12 months (36 months for BCBSOK)