Furoscix — Blue Cross Blue Shield of Montana

rare disease

Initial criteria

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
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 peer-reviewed journal articles supporting the proposed use as generally safe and effective (acceptable designs: randomized, double blind, placebo controlled clinical trials; case studies not acceptable)
Non-oncology compendia allowed: DrugDex level 1, 2A, 2B; AHFS-DI narrative text supportive
Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI supportive, DrugDex level 1, 2A, 2B, Clinical Pharmacology supportive, LexiDrugs evidence level A, or peer-reviewed medical literature

12 months