Vibramycin — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. The member resides in Ohio AND 2. The plan is Fully Insured or HIM Shop (SG) AND 3. The patient does NOT have any FDA labeled contraindications to the requested agent AND 4. ONE of the following: A. The patient has another FDA labeled indication for the requested agent and route of administration OR B. The patient has another indication supported in compendia for the requested agent and route of administration OR C. The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use(s) as generally safe and effective (case studies not acceptable; specific journal standards and compendia evidence levels required).

Approval duration

12 months (36 months for BCBSOK)