Cortrophin Gel (repository corticotropin) — Blue Cross Blue Shield of New Mexico

Rare diseases as outlined for BCBS NM Fully Insured or NM HIM members or for Ohio Fully Insured or HIM Shop members

Preferred products

Patient does NOT have any FDA labeled contraindications to the requested agent
Requested indication is a rare disease
AND ONE of the following:
A. Patient has another FDA labeled indication for the requested agent and route of administration OR
B. 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:
Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
AND ONE of the following:
1. Patient has another FDA labeled indication for the requested agent and route of administration OR
2. Patient has another indication that is supported in compendia for the requested agent and route of administration OR
3. Prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective

12 months