Bonjesta — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. Request for a BCBS NM Fully Insured or NM HIM member requires ALL: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease AND (C) 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 supported in compendia for the requested agent and route OR
• 2. For members residing in Ohio and plan is Fully Insured or HIM Shop (SG): ALL must be met: (A) The patient does NOT have contraindications to the requested agent AND (B) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route OR (2) The patient has another indication supported in compendia for the requested agent and route OR (3) The prescriber has submitted two articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective; accepted designs include randomized, double-blind, placebo-controlled clinical trials (case studies not acceptable).

Approval duration

12 months