cannabidiol — Blue Cross Blue Shield of Oklahoma

rare disease indications under BCBS NM Fully Insured or NM HIM or Ohio Fully Insured/HIM Shop plans

Initial criteria

For BCBS NM Fully Insured or NM HIM members: ALL of the following must be met: (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 applies: (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 of administration
OR for Ohio Fully Insured or HIM Shop (SG) members: ALL of the following must be met: (A) The member resides in Ohio AND (B) The plan is Fully Insured or HIM Shop (SG) AND (C) The patient does NOT have any FDA labeled contraindications to the requested agent AND (D) ONE of the following applies: (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 of administration OR (3) The prescriber has submitted TWO peer-reviewed medical journal articles (e.g., JAMA, NEJM, Lancet) supporting safety and efficacy; case studies not acceptable

12 months