Evrysdi — Blue Cross Blue Shield of New Mexico
other FDA labeled or compendia supported indications (Ohio fully insured or HIM Shop plans)
Initial criteria
- Member resides in Ohio
- Plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to requested agent
- 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 supported in compendia for requested agent and route of administration OR (C) Prescriber has submitted TWO peer-reviewed articles supporting safe and effective use
Approval duration
12 months