Firdapse — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Member resides in Ohio
• Plan is Fully Insured or HIM Shop (SG)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective (case studies not acceptable; acceptable compendia and evidence levels specified)

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, oncologist) OR has consulted with a specialist in the area of the patient’s diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months