amikacin sulfate liposome — Blue Cross Blue Shield of New Mexico

Initial criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (1) the patient has another FDA labeled indication for the requested agent and route of administration OR (2) the patient has another indication that is supported in compendia for the requested agent and route of administration OR (3) the prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (note: case studies not acceptable; acceptable compendia include DrugDex level 1, 2A, or 2B; AHFS-DI supportive text; oncology compendia such as NCCN 1 or 2A, DrugDex 1/2A/2B, Clinical Pharmacology supportive narrative, LexiDrugs level A)

Approval duration

12 months