Northera — 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:
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• ONE of the following:
• The patient has another FDA labeled indication for the requested agent and route of administration OR
• The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective

Approval duration

12 months