fitusiran sodium — Blue Cross Blue Shield of Montana

rare disease indications (BCBS NM, OH members)

Initial criteria

For BCBS NM Fully Insured or NM HIM members: ALL of the following: patient has no FDA-labeled contraindications AND requested indication is a rare disease AND (A) another FDA-labeled indication for the requested agent and route OR (B) another indication supported in compendia (DrugDex level 1, 2A, 2B; AHFS-DI supportive).
For Ohio Fully Insured or HIM Shop members: ALL of the following: member resides in Ohio AND plan Fully Insured or HIM Shop AND patient has no FDA-labeled contraindications AND ONE of the following: (A) another FDA-labeled indication for agent and route OR (B) indication supported in compendia (NCCN 1 or 2A; AHFS-DI supportive; DrugDex 1, 2A, 2B; Clinical Pharmacology supportive; LexiDrugs evidence level A) OR (C) prescriber submitted TWO peer-reviewed journal articles (JAMA, NEJM, Lancet, etc.) supporting safe/effective proposed use (not case studies).

12 months