Emflaza — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. Member resides in Ohio
• 2. Plan is Fully Insured or HIM Shop (SG)
• 3. Patient has no FDA labeled contraindications to the requested agent
• 4. ONE of the following: patient has another FDA labeled indication for the requested agent and route of administration OR patient’s indication is supported in compendia for the requested agent and route of administration (DrugDex level 1, 2A or 2B; AHFS-DI supportive text for non-oncology; NCCN 1 or 2A, AHFS-DI supportive text, DrugDex level 1, 2A, or 2B, Clinical Pharmacology supportive text, Lexi-Drugs evidence level A, or peer-reviewed medical literature for oncology) OR prescriber submitted two peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective (case studies not accepted)

Approval duration

BCBSOK: 36 months; others: 12 months