Xdemvy — Blue Cross Blue Shield of Oklahoma
Ohio fully insured or HIM Shop (SG) members with FDA labeled or compendia supported or peer-reviewed literature supported indication
Initial criteria
- 1. The member resides in Ohio AND
- 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
- A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
- B. ONE of the following: The patient has another FDA labeled indication for the requested agent and route of administration OR The patient has another indication supported in compendia OR The prescriber has submitted TWO peer-reviewed major medical journal articles (e.g., JAMA, NEJM, Lancet) showing proposed use is safe and effective. Case studies not acceptable.
Approval duration
12 months