Restasis — Blue Cross Blue Shield of Montana

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• AND The patient does NOT have any FDA labeled contraindications to the requested agent
• AND ONE of the following:
• • The patient has another FDA labeled indication for the requested agent and route of administration
• • The patient has another indication supported in compendia for the requested agent and route of administration
• • The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (randomized, double blind, placebo controlled clinical trials; case studies not acceptable)