Hyftor — Blue Cross Blue Shield of Oklahoma
non-FDA labeled or compendia-supported indications (Ohio fully insured or HIM Shop members)
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 that is supported in compendia (DrugDex level 1, 2A, or 2B; AHFS-DI supportive; NCCN 1 or 2A; Clinical Pharmacology supportive; LexiDrugs evidence level A; or peer-reviewed medical literature) OR (3) Prescriber has submitted TWO articles from major peer-reviewed journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective (case studies not acceptable)
Approval duration
12 months