doxepin hydrochloride cream 5% — Blue Cross Blue Shield of Oklahoma

rare disease

Initial criteria

For BCBS NM Fully Insured or NM HIM members:
1. Patient does NOT have any FDA labeled contraindications to requested agent AND
2. Requested indication is a rare disease AND
3. ONE of the following:
A. Patient has another FDA labeled indication for requested agent and route OR
B. Patient has another indication supported in compendia for requested agent and route
For Ohio Fully Insured or HIM Shop (SG) members:
1. Member resides in Ohio AND
2. Plan is Fully Insured or HIM Shop (SG) AND
3. Patient does NOT have any FDA labeled contraindications to requested agent AND
4. ONE of the following:
A. Patient has another FDA labeled indication for requested agent and route OR
B. Patient has another indication supported in compendia for requested agent and route OR
C. Prescriber has submitted TWO peer-reviewed journal articles (not case studies) supporting the proposed use as safe and effective

12 months