Vibramycin — Blue Cross Blue Shield of Montana
FDA labeled indications
Initial criteria
- The member resides in Ohio AND
- The 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:
- A. The patient has another FDA labeled indication for the requested agent and route of administration OR
- B. The patient has another indication supported in compendia for the requested agent and route of administration OR
- C. The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective (randomized, double blind, placebo controlled acceptable; case studies not acceptable)
Approval duration
12 months (36 months for BCBSOK)