Diclegis — Blue Cross Blue Shield of Texas

Initial criteria

• For BCBS NM Fully Insured or NM HIM member: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) The requested indication is a rare disease AND (C) 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 For Ohio members (Fully Insured or HIM Shop (SG)): (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) 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 (3) The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use(s)

Approval duration

12 months