PCSK9 inhibitors — Blue Cross Blue Shield of Montana

members under age 18 with off-label use supported by journal evidence (MT)

Initial criteria

For BCBS MT Fully Insured or MT HIM members: patient age < 18 years AND has no FDA labeled contraindications AND indication supported in two major peer-reviewed medical journal articles as generally safe and effective AND support for patient’s age bracket (infancy, childhood, adolescence) in two journal articles as safe and effective (randomized, double blind, placebo controlled; case studies not acceptable)
For BCBS NM Fully Insured or NM HIM members: patient has no FDA labeled contraindications AND requested indication is a rare disease AND patient has another FDA labeled indication OR an indication supported in compendia
For Ohio members (Fully Insured or HIM Shop): patient has no FDA labeled contraindications AND has another FDA labeled or compendia-supported indication OR prescriber has submitted two major peer-reviewed journal articles supporting safe and effective proposed use

12 months