zilucoplan sodium — Blue Cross Blue Shield of Montana

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