belumosudil mesylate — Blue Cross Blue Shield of New Mexico

Off-label use or other FDA labeled indications (Ohio Residents, Fully Insured or HIM Shop plans)

Initial criteria

The member resides in Ohio
AND The plan is Fully Insured or HIM Shop (SG)
AND BOTH of the following:
A. The patient does NOT have any FDA labeled contraindications to the requested agent
AND B. 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 (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective

The patient has been previously approved for the requested agent through the plan’s Prior Authorization Review process
AND The patient has had clinical benefit with the requested agent
AND The prescriber is a specialist in the area of the patient’s diagnosis or has consulted with a specialist
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 months