budesonide delayed release cap 4 mg — Blue Cross Blue Shield of Oklahoma

other FDA-labeled or compendia-supported indication (Ohio residents, Fully Insured or HIM Shop plans)

Initial criteria

ALL of the following:
1. Member resides in Ohio AND
2. Plan is Fully Insured or HIM Shop (Small Group) AND
3. Patient does NOT have any FDA-labeled contraindications to the requested agent AND
4. ONE of the following: (A) Patient has another FDA-labeled indication and route of administration OR (B) Patient has another indication supported in compendia for requested agent and route of administration OR (C) Prescriber submits two peer‑reviewed journal articles supporting the proposed use as generally safe and effective (acceptable study designs include randomized, double-blind, placebo-controlled trials; case studies not acceptable)
Compendia and evidence sources accepted: DrugDex level 1, 2A, or 2B; AHFS-DI (supportive narrative); NCCN 1 or 2A; Clinical Pharmacology (supportive narrative); LexiDrugs evidence level A; peer-reviewed medical literature

12 months