zilucoplan sodium — Blue Cross Blue Shield of Montana
off-label indication supported by ≥2 peer-reviewed journal articles
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient has no FDA-labeled contraindications to requested agent
- ONE of the following:
- - Has another FDA-labeled indication for the requested agent and route of administration
- - Has an indication supported in compendia (non-oncology: DrugDex level 1, 2A, or 2B, or AHFS-DI supportive; oncology: NCCN 1 or 2A, AHFS-DI supportive, DrugDex level 1, 2A, or 2B, Clinical Pharmacology supportive, Lexi-Drugs level A, or peer-reviewed literature supportive)
- - Prescriber submitted two peer-reviewed journal articles (major journals, e.g., JAMA, NEJM, Lancet) showing proposed use is generally safe and effective
Approval duration
12 months