metformin — Blue Cross Blue Shield of Oklahoma

Initial criteria

• For BCBS NM Fully Insured or NM HIM member: ALL of the following must be met:
• • Patient does NOT have any FDA labeled contraindications to the requested agent AND
• • Requested indication is a rare disease AND
• • ONE of the following:
• – Patient has another FDA labeled indication for the requested agent and route of administration OR
• – Patient has another indication that is supported in compendia for the requested agent and route of administration
• For Ohio Fully Insured or HIM Shop (SG) member: ALL of the following must be met:
• • Member resides in Ohio AND
• • Plan is Fully Insured or HIM Shop (SG) AND
• • Patient does NOT have any FDA labeled contraindications to the requested agent AND
• • ONE of the following:
• – Patient has another FDA labeled indication for the requested agent and route of administration OR
• – Patient has another indication that is supported in compendia for the requested agent and route of administration OR
• – Prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (accepted study designs may include randomized, double blind, placebo controlled clinical trials; case studies not acceptable)

Approval duration

12 months