Oxervate — Blue Cross Blue Shield of New Mexico

Initial criteria

• For BCBS MT Fully Insured or MT HIM member: A. The patient is under the age of 18 years AND B. The patient does NOT have any FDA labeled contraindications to the requested agent AND C. The patient has an indication supported in TWO articles from major peer-reviewed professional medical journals (JAMA, NEJM, Lancet) as generally safe and effective (case studies not acceptable) AND D. There is support for the patient’s age bracket (infancy, childhood, adolescence) in TWO articles from major peer-reviewed professional medical journals as generally safe and effective
• For Ohio residents (Fully Insured or HIM Shop): A. The member resides in Ohio AND B. The plan is Fully Insured or HIM Shop (SG) AND C. The patient does NOT have any FDA labeled contraindications to the requested agent AND D. 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 supported in compendia for the requested agent and route of administration OR 3. The prescriber has submitted TWO articles from major peer-reviewed medical journals supporting the proposed use as generally safe and effective (case studies not acceptable)

Approval duration

12 months