Mavenclad (cladribine) — Blue Cross Blue Shield of New Mexico

Initial criteria

• Request for BCBS MT Fully Insured or MT HIM member AND the patient is under age 18 years
• The patient does NOT have any FDA labeled contraindications to the requested agent
• The patient has an indication that is supported in TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) as generally safe and effective. Accepted study designs include randomized, double blind, placebo controlled clinical trials; case studies are not acceptable
• There is support for an age in the patient’s given age bracket in TWO articles from major peer-reviewed professional medical journals as generally safe and effective. Age brackets: infancy (birth to <2 years), childhood (2–11 years), adolescence (12–17 years)