Duvyzat (givinostat hcl oral suspension 8.86 MG/ML) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. The member resides in Ohio AND
• 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• A. The patient does NOT have any FDA labeled 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 of administration OR
• 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (e.g., randomized, double blind, placebo controlled clinical trials)

Approval duration

12 months