furosemide subcutaneous cartridge kit — Blue Cross Blue Shield of Montana

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

Approval duration

12 months