olezarsen sodium subcutaneous solution auto-injector — Blue Cross Blue Shield of Montana
patients residing in Ohio with Fully Insured or HIM Shop (SG) plan and other FDA labeled or compendia supported indications
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient has no FDA labeled contraindications
- ONE of the following: (A) FDA labeled indication for the requested agent and route OR (B) indication supported in compendia OR (C) prescriber has submitted two peer-reviewed journal articles supporting the use as safe and effective
Approval duration
12 months