sparsentan — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. Member resides in Ohio AND
• 2. Plan is Fully Insured or HIM Shop (SG) AND
• 3. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• 4. ONE of the following: (A) Patient has another FDA labeled indication for the requested agent and route OR (B) Patient has another indication supported in compendia for the agent and route OR (C) Prescriber submitted two peer-reviewed professional medical journal articles supporting proposed use as generally safe and effective

Approval duration

12 months