Seysara — Blue Cross Blue Shield of Oklahoma
off-label use for other indications (Ohio plan members)
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient has no FDA labeled contraindications to requested agent
- ONE of the following:
- A. Has another FDA labeled indication for requested agent and route OR
- B. Has indication supported in compendia (DrugDex level 1, 2A, 2B, AHFS-DI supportive text) OR
- C. Prescriber has submitted TWO peer-reviewed journal articles supporting proposed use as safe and effective (randomized, double blind, placebo controlled acceptable; case studies not acceptable)
Reauthorization criteria
- Same as initial criteria
Approval duration
36 months (BCBSOK); 12 months (others)