Zelsuvmi — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Request is for a BCBS NM Fully Insured or NM HIM member AND ALL of the following: (A) The patient does NOT have any FDA labeled contraindications to the requested agent; (B) The requested indication is a rare disease; and ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication that is supported in compendia for the requested agent and route of administration
• OR ALL of the following: (A) The member resides in Ohio; (B) The plan is Fully Insured or HIM Shop (SG); (C) The patient does NOT have any FDA labeled contraindications to the requested agent; and ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective (acceptable journals include JAMA, NEJM, Lancet; case studies not acceptable)

Approval duration

12 months