budesonide delayed release cap — Blue Cross Blue Shield of Texas

Initial criteria

• Member resides in Ohio AND
• Plan is Fully Insured or HIM Shop (SG) AND
• Patient does NOT have any FDA labeled contraindications to the requested agent AND
• Patient has another FDA labeled indication for the requested agent and route of administration OR indication supported in compendia OR prescriber submitted two peer-reviewed journal articles supporting the proposed use as generally safe and effective (non-oncology compendia DrugDex level 1, 2A, or 2B; AHFS-DI supportive; oncology compendia NCCN 1 or 2A, AHFS-DI supportive, DrugDex level 1, 2A, or 2B, Clinical Pharmacology supportive, or LexiDrugs evidence level A)

Approval duration

12 months