Austedo XR — Blue Cross Blue Shield of Oklahoma
off-label use by Ohio members
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH:
- A. No FDA labeled contraindications AND
- B. ONE of: (1) Another FDA labeled indication OR (2) Compendia supported indication OR (3) Prescriber submitted TWO peer-reviewed journal articles demonstrating safety and efficacy (not case studies).
- Non-oncology compendia allowed: DrugDex 1,2A,2B; AHFS-DI supportive narrative.
- Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI supportive, DrugDex 1,2A,2B, Clinical Pharmacology supportive, LexiDrugs evidence level A, or peer-reviewed literature.
Approval duration
12 months