Vanrafia (atrasentan hcl) — Blue Cross Blue Shield of New Mexico

Initial criteria

• ALL of the following: (A) Member resides in Ohio AND (B) Plan is Fully Insured or HIM Shop (SG) AND (C) 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 that is supported in compendia (DrugDex level 1, 2A or 2B; AHFS-DI supportive narrative text for non-oncology; NCCN 1 or 2A; AHFS-DI; DrugDex level 1, 2A, or 2B; Clinical Pharmacology; LexiDrugs evidence level A; peer-reviewed medical literature for oncology) 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 (case studies not acceptable)

Approval duration

12 months