Imcivree (setmelanotide acetate) — Blue Cross Blue Shield of Oklahoma
other indication supported by peer-reviewed clinical literature
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient has no FDA labeled contraindications to requested agent
- Patient has another FDA labeled indication for requested route OR indication supported in compendia (DrugDex level 1,2A,2B; AHFS-DI supportive text; NCCN 1 or 2A; Clinical Pharmacology supportive; LexiDrugs level A; or peer-reviewed literature) OR prescriber submitted two peer-reviewed medical journal articles demonstrating safety and effectiveness
- Case studies not acceptable
Approval duration
12 months