Qbrexza — Blue Cross Blue Shield of Montana

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (1) patient has another FDA labeled indication for the requested agent and route OR (2) patient has another indication supported in compendia (DrugDex 1, 2A, 2B; AHFS-DI; NCCN 1, 2A; Clinical Pharmacology narrative supportive; LexiDrugs level A; peer-reviewed medical literature) OR (3) prescriber submitted TWO major peer-reviewed journal articles supporting use as generally safe and effective

Approval duration

12 months