sparsentan — Blue Cross Blue Shield of Montana
members residing in Ohio with FDA labeled or compendia-supported indications
Initial criteria
- Member resides in Ohio AND
- Plan is Fully Insured or HIM Shop (SG) AND
- Patient has no FDA labeled contraindications to requested agent AND
- ONE of the following: (A) Patient has another FDA labeled indication for agent and route OR (B) Patient has indication supported in compendia for requested agent and route OR (C) Prescriber submitted TWO peer-reviewed journal articles supporting proposed use as safe and effective
Approval duration
12 months