Accrufer — Blue Cross Blue Shield of Oklahoma

rare disease

Initial criteria

If the patient has an FDA labeled indication, then ONE of the following: (A) The patient's age is within FDA labeling for the requested indication OR (B) There is support for using the requested agent for the patient's age for the requested indication
The patient does NOT have any FDA labeled contraindications to the requested agent
For BCBS NM Fully Insured or NM HIM: (A) No FDA labeled contraindications AND (B) Requested indication is a rare disease AND (C) ONE of: (1) Another FDA labeled indication for the requested agent and route OR (2) Another indication supported in compendia
For Ohio residents, Fully Insured or HIM Shop plan: (A) No FDA labeled contraindications AND (B) ONE of: (1) Another FDA labeled indication for the requested agent and route OR (2) Another indication supported in compendia OR (3) Two published peer-reviewed journal articles support proposed use as safe and effective (not case studies)

Patient was previously approved for the requested agent through the plan's prior authorization process
Patient has had clinical benefit with the requested agent
Patient does NOT have any FDA labeled contraindications to the requested agent

36 months (BCBSOK); 12 months (BCBSIL, BCBSMT, others initial 6 months then renewal 12 months)