fluticasone propionate nasal exhaler — Blue Cross Blue Shield of Oklahoma
rare disease cases for BCBS NM Fully Insured or NM HIM members
Initial criteria
- For BCBS NM Fully Insured or NM HIM members: ALL of the following must be met: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease AND (C) 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.
- For Ohio residents with Fully Insured or HIM Shop (SG) plans: ALL of the following must be met: (A) The member resides in Ohio AND (B) The plan is Fully Insured or HIM Shop (SG) AND (C) The patient does NOT have any FDA labeled contraindications to the requested agent AND (D) 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 (case studies are not acceptable).
- Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative supportive).
- Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative supportive), DrugDex level 1, 2A or 2B, Clinical Pharmacology (narrative supportive), or LexiDrugs evidence level A, peer-reviewed medical literature.
Approval duration
12 months