sirolimus gel 0.2 % — Blue Cross Blue Shield of New Mexico

other FDA labeled or compendia-supported indications for sirolimus gel

Initial criteria

1. The member resides in Ohio AND
2. 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 supported in compendia for the requested agent and route of administration OR
3. The prescriber has submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective. Accepted designs include randomized, double-blind, placebo-controlled clinical trials. Case studies not acceptable. Accepted compendia: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative; NCCN 1 or 2A; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A.

12 months