berdazimer sodium gel 10.3 % — Blue Cross Blue Shield of New Mexico

rare disease (for BCBS NM Fully Insured or NM HIM member, or Ohio Fully Insured/HIM Shop members)

Initial criteria

1. The patient does NOT have any FDA labeled contraindications to the requested agent AND
2. The requested indication is a rare disease AND
3. 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 that is supported in compendia for the requested agent and route of administration
OR For Ohio Fully Insured or HIM Shop (SG) members: ALL of the following must be met: A. The member resides in Ohio AND B. The plan is Fully Insured or HIM Shop (SG) AND C. The patient does NOT have any FDA labeled contraindications to the requested agent AND D. 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 (accepted study designs: randomized, double blind, placebo controlled clinical trials; case studies not acceptable)

12 months