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furosemide subcutaneous cartridge kit — Blue Cross Blue Shield of Oklahoma

other FDA labeled indications for the requested agent and route of administration

Initial criteria

  • ONE of the following: (A) Patient has a diagnosis of edema with chronic heart failure or chronic kidney disease (including nephrotic syndrome) AND BOTH of the following: (1) Patient was treated with an oral loop diuretic total daily dose of 40–160 mg furosemide equivalent AND (2) Patient will NOT be using the requested agent in combination with another loop diuretic and will transition back to oral diuretic therapy after completion of the requested agent; OR (B) Patient has another FDA labeled indication for the requested agent and route of administration
  • AND if the patient has an FDA labeled indication, then ONE of the following: (A) Patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for use of the requested agent for the patient’s age for the requested indication
  • AND the prescriber is a specialist (e.g., cardiologist, nephrologist) or has consulted with a specialist in the area of the patient’s diagnosis
  • AND the patient does NOT have any FDA labeled contraindications to the requested agent
  • Alternate approval pathway for BCBS NM Fully Insured or NM HIM member: ALL of the following – (A) No FDA labeled contraindications to the requested agent AND (B) Requested indication is a rare disease AND (C) ONE of the following – (1) Patient has another FDA labeled indication; OR (2) Patient has another indication supported in compendia for the requested agent and route of administration
  • Alternate approval pathway for Ohio: ALL of the following – (A) Member resides in Ohio AND (B) Plan is Fully Insured or HIM Shop (SG) AND (C) No FDA labeled contraindications AND (D) ONE of the following – (1) Patient has another FDA labeled indication; OR (2) Patient has indication supported in compendia; OR (3) Prescriber submitted two peer-reviewed journals supporting proposed use (acceptable study designs include randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

Approval duration

12 months