amikacin sulfate liposome — Blue Cross Blue Shield of Oklahoma
Other FDA labeled or compendia supported indications; Ohio-specific criteria
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to requested agent
- ONE of the following: (A) Patient has another FDA labeled indication for the requested agent and route of administration OR (B) Patient has another indication supported in compendia for requested agent and route OR (C) Prescriber submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective; accepted study designs include randomized, double blind, placebo controlled clinical trials (case studies not acceptable)
- Allowed non-oncology compendia: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative. Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI supportive narrative; DrugDex level 1, 2A, or 2B; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; peer-reviewed medical literature
Approval duration
12 months