Movantik (naloxegol) — Blue Cross Blue Shield of New Mexico

Initial criteria

• The member resides in Ohio; AND
• The plan is Fully Insured or HIM Shop (SG); AND BOTH of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent; AND
• B. 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 peer-reviewed journal articles supporting the proposed use as generally safe and effective (randomized, double-blind, placebo-controlled trials preferred; case studies not acceptable).
• Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (supportive narrative).
• Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (supportive narrative), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (supportive narrative), LexiDrugs evidence level A, peer-reviewed medical literature.

Approval duration

12 months