Vanrafia — Blue Cross Blue Shield of Montana
other FDA labeled indications; compendia supported off-label indications (non-oncology and oncology)
Initial criteria
- ALL of the following: (A) Member resides in Ohio AND (B) Plan is Fully Insured or HIM Shop (SG) AND (C) No FDA labeled contraindications to the requested agent AND
- ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber submitted two articles from major peer-reviewed journals (e.g., JAMA, NEJM, Lancet) supporting proposed use(s) as generally safe and effective (randomized, double blind, placebo controlled trials acceptable; case studies not acceptable)
Approval duration
12 months