ruxolitinib phosphate cream 1.5% — Blue Cross Blue Shield of Oklahoma

Other FDA labeled or compendia supported indications (Ohio only)

Initial criteria

Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications
ONE of the following:
A. Has another FDA labeled indication for requested agent and route of administration OR
B. Has another indication supported in compendia for agent and route OR
C. Prescriber submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as generally safe and effective (randomized, double-blind, placebo-controlled trials accepted; case studies not accepted)
Allowed compendia references: DrugDex level 1, 2A or 2B; AHFS-DI with supportive narrative; Oncology: NCCN 1 or 2A, AHFS-DI, DrugDex 1–2B, Clinical Pharmacology supportive narrative, LexiDrugs evidence level A, peer-reviewed literature

12 months