Horizant — Blue Cross Blue Shield of Montana

rare disease

Initial criteria

The requested agent will also be approved when ALL of the following are met:
1. The request is for a BCBS NM Fully Insured or NM HIM member AND
2. The patient does NOT have any FDA labeled contraindications to the requested agent AND
3. The requested indication is a rare disease AND
4. ONE of the following:
A. The patient has another FDA labeled indication for the requested agent and route of administration OR
B. The patient has another indication that is supported in compendia for the requested agent and route of administration

12 months