Hympavzi — Blue Cross Blue Shield of Oklahoma
Off-label or rare disease use under BCBS MT, BCBS NM, or Ohio Fully Insured/HIM plans
Initial criteria
- For BCBS MT Fully Insured or MT HIM: patient age <18 years, no FDA labeled contraindications, indication supported in TWO peer-reviewed journal articles as generally safe/effective, and age group supported in TWO such articles.
- For BCBS NM Fully Insured or NM HIM: indication is a rare disease, no FDA labeled contraindications, and ONE of: another FDA labeled indication for agent, indication supported in compendia, or TWO peer-reviewed articles supporting use as generally safe and effective.
- For Ohio Fully Insured or HIM Shop (SG): member resides in Ohio, plan Fully Insured or HIM Shop, no FDA labeled contraindications, and ONE of: another FDA labeled indication for the agent, indication supported in compendia, or TWO peer-reviewed journal articles supporting safety/effectiveness.
Reauthorization criteria
- Continuation requires reassessment that off-label indication remains valid under literature/compendia support and patient continues to benefit.
Approval duration
36 months (BCBSOK); 12 months (other plans)