tolvaptan — Blue Cross Blue Shield of New Mexico

Initial criteria

• The member resides in Ohio
• The plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• 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 articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective
• Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text must be supportive)
• Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative text must be supportive), DrugDex level 1, 2A, or 2B, or Clinical Pharmacology (narrative text must be supportive), LexiDrugs evidence level A, peer-reviewed medical literature

Approval duration

12 months