doxepin hydrochloride cream 5% — Blue Cross Blue Shield of Texas

rare disease or other labeled/compendia-supported indication (NM and OH plan exceptions)

Initial criteria

For BCBS NM Fully Insured or NM HIM member:
A. The patient does NOT have any FDA labeled contraindications AND
B. The 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 OR
2. The patient has another indication supported in compendia for the requested agent and route
OR for OH Fully Insured or HIM Shop (SG) members:
A. The member resides in Ohio AND
B. The plan is Fully Insured or HIM Shop (SG) AND
C. The patient does NOT have any FDA labeled contraindications AND
D. ONE of the following:
1. The patient has another FDA labeled indication for the requested agent and route OR
2. The patient has another indication supported in compendia for the requested agent and route OR
3. The prescriber has submitted TWO peer-reviewed journal articles supporting generally safe and effective use

12 months