sacrosidase — Blue Cross Blue Shield of Montana

any indication supported by FDA label or compendia for members in Ohio on Fully Insured or HIM Shop plans

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: patient has another FDA labeled indication; OR patient has an indication supported in non-oncology or oncology compendia as defined (DrugDex level 1, 2A, or 2B; AHFS-DI supportive; NCCN 1 or 2A; Clinical Pharmacology or LexiDrugs supportive); OR prescriber provides two peer-reviewed journal articles supporting requested use

12 months