ferric maltol — Blue Cross Blue Shield of Montana

Initial criteria

• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The patient does NOT have any FDA labeled contraindications to the requested agent
• The requested agent will also be approved when ONE of the following is met: (1) The request is for a BCBS NM Fully Insured or NM HIM member and ALL of the following: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease AND (C) 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 that is supported in compendia for the requested agent and route of administration) OR
• (2) ALL of the following: (A) The member resides in Ohio AND (B) The plan is Fully Insured or HIM Shop (SG) AND (C) The patient does NOT have any FDA labeled contraindications to the requested agent AND (D) 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 that is supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective)

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested agent
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSOK: 36 months; BCBSIL and BCBSMT: 12 months; others: 6–12 months