marstacimab-hncq — Blue Cross Blue Shield of Montana
Off-label uses for BCBS MT, NM, and OH members per plan exceptions
Initial criteria
- BCBS MT Fully Insured or MT HIM members:
- • Patient age < 18 years
- • No FDA labeled contraindications
- • Indication supported in TWO articles from major peer-reviewed journals (e.g., JAMA, NEJM, Lancet) as generally safe and effective (case studies not accepted)
- • Age support in TWO peer-reviewed articles for same age bracket (infancy, childhood, adolescence) as generally safe and effective
- BCBS NM Fully Insured or NM HIM members:
- • No FDA labeled contraindications
- • Indication is rare disease
- • ONE of:
- - Has another FDA labeled indication for requested agent and route OR
- - Has another indication supported in compendia OR
- - Submitted TWO peer-reviewed articles showing proposed use generally safe and effective
- OH Fully Insured or HIM Shop (SG) members:
- • Member resides in Ohio
- • Plan is Fully Insured or HIM Shop (SG)
- • No FDA labeled contraindications
- • ONE of:
- - Has another FDA labeled indication for requested agent and route OR
- - Has another indication supported in compendia OR
- - TWO peer-reviewed journal articles (JAMA, NEJM, Lancet) support proposed use as generally safe and effective (case studies not acceptable)
Approval duration
12 months (all except BCBSOK 36 months)