pitolisant hcl — Blue Cross Blue Shield of Montana
other FDA labeled indication
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- AND patient does NOT have any FDA labeled contraindications
- AND ONE of the following: (1) patient has another FDA labeled indication for requested agent and route OR (2) patient has another indication supported in compendia OR (3) prescriber has submitted TWO supporting peer-reviewed journal articles showing safety and efficacy
Approval duration
12 months