Evrysdi — Blue Cross Blue Shield of Montana

any indication supported by compendia or peer-reviewed literature (for Ohio fully insured or HIM Shop plans)

Initial criteria

Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO articles from major peer-reviewed journals supporting the proposed use(s) as generally safe and effective (case studies not acceptable)

12 months