dextromethorphan hbr-quinidine sulfate — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The member resides in Ohio AND
• The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• The patient does NOT have any FDA labeled contraindications to the requested agent AND ONE of the following:
• The patient has another FDA labeled indication for the requested agent and route of administration OR
• The patient has another indication supported in compendia for the requested agent and route of administration (DrugDex level 1, 2A, 2B; AHFS-DI narrative supportive; NCCN 1 or 2A; Clinical Pharmacology or LexiDrugs narrative supportive) OR
• The prescriber has submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting the proposed off-label use as generally safe and effective (case studies not acceptable)

Approval duration

12 months