Arikayce — Blue Cross Blue Shield of Texas

Other FDA labeled or compendia-supported indications (Ohio fully insured or HIM Shop members)

Initial criteria

1. Member resides in Ohio AND
2. Plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. No FDA labeled contraindications to the requested agent AND
B. ONE of the following:
1. Patient has another FDA labeled indication for the requested agent and route of administration OR
2. Patient has another indication that is supported in compendia for the requested agent and route of administration OR
3. Prescriber has submitted TWO articles from major peer-reviewed medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective (randomized, double-blind, placebo-controlled clinical trials acceptable; case studies not accepted)

12 months