fecal microbiota spores, live-brpk caps — Blue Cross Blue Shield of Oklahoma

Initial criteria

• For BCBS MT Fully Insured or MT HIM members: Patient age <18 years; no FDA‑labeled contraindications; indication supported by two articles from major peer‑reviewed medical journals as generally safe and effective; support for patient age bracket demonstrated in two peer‑reviewed journal articles (infancy, childhood, or adolescence categories)
• For BCBS NM Fully Insured or NM HIM members: no FDA‑labeled contraindications; requested indication is a rare disease; and one of the following—patient has another FDA‑labeled indication for the agent and route, or another indication supported in compendia for the agent and route, or meets Ohio criteria below
• For Ohio residents with Fully Insured or HIM Shop plan: patient resides in Ohio; plan is Fully Insured or HIM Shop (SG); no FDA‑labeled contraindications; and one of the following—patient has another FDA‑labeled indication for the agent and route, another indication supported in compendia, or prescriber has submitted two peer‑reviewed journal articles supporting proposed use as generally safe and effective (no case studies accepted)

Approval duration

1 course per 12 months