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Horizant — Blue Cross Blue Shield of New Mexico

rare disease

Initial criteria

  • Request is for a BCBS NM Fully Insured or NM HIM member AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • The requested indication is a rare disease AND
  • 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 (Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI; Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI, DrugDex level 1, 2A, or 2B, Clinical Pharmacology, or Lexi-Drugs evidence level A)

Approval duration

12 months