Xyrem — Blue Cross Blue Shield of Oklahoma
any FDA labeled or compendia supported indication when member resides in Ohio and plan is Fully Insured or HIM Shop
Initial criteria
- Member resides in Ohio AND
- Plan is Fully Insured or HIM Shop (SG) AND
- No FDA labeled contraindications AND
- ONE of:
- Patient has another FDA labeled indication and route of admin OR
- Patient has another indication supported in compendia OR
- Prescriber submitted two peer-reviewed professional medical journal articles supporting proposed use (acceptable high-quality study designs)
Approval duration
12 months