fecal microbiota spores, live-brpk caps — Blue Cross Blue Shield of Montana
non‑FDA or pediatric and rare disease or compendia-supported use (BCBS MT/NM/OH Fully Insured/HIM members)
Initial criteria
- For BCBS MT Fully Insured or MT HIM member: (A) patient age < 18 years AND (B) patient does NOT have FDA labeled contraindications AND (C) indication supported in TWO major peer‑reviewed medical journal articles as generally safe and effective AND (D) age group supported in TWO major peer‑reviewed medical journal articles as generally safe and effective
- For BCBS NM Fully Insured or NM HIM member: (A) patient does NOT have FDA labeled contraindications AND (B) requested indication is a rare disease AND (C) ONE of the following: (1) another FDA labeled indication for the same agent and route OR (2) another indication supported in compendia for the same agent and route
- For members residing in Ohio with Fully Insured or HIM Shop (SG) plans: (A) patient resides in Ohio AND (B) plan is Fully Insured or HIM Shop (SG) AND (C) patient does NOT have FDA labeled contraindications AND (D) ONE of the following: (1) another FDA labeled indication for the requested agent and route OR (2) another indication supported in compendia for the agent and route OR (3) prescriber submitted TWO major peer‑reviewed journal articles supporting proposed use as safe and effective
Approval duration
1 course per 12 months