Dexcom G6 — Blue Cross Blue Shield of Texas

off-label or alternative FDA or compendia-supported indications

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
A. Patient has 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 supported in compendia for the requested agent and route of administration OR
3. Prescriber has submitted two peer-reviewed journal articles supporting the proposed use as generally safe and effective (acceptable study designs include randomized, double-blind, placebo controlled clinical trials; case studies not acceptable)

For ongoing treatment, criteria remain the same as initial approval; documentation of continued clinical need and absence of contraindication must be provided.

12 months