alpelisib (PROS) — Blue Cross Blue Shield of Texas
Other FDA labeled or compendia-supported indications (Ohio members only)
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does not have any FDA labeled contraindications to the requested agent
- ONE of the following applies: patient has another FDA labeled indication for the requested agent and route of administration OR patient has an indication supported in compendia for the requested agent and route of administration OR prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective (note: case studies not acceptable)
- Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text must be supportive)
- Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative text must be supportive), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (narrative text must be supportive), or LexiDrugs evidence level A
Approval duration
12 months