Empaveli (pegcetacoplan) — Blue Cross Blue Shield of Texas

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• Patient does NOT have any FDA labeled contraindications to Empaveli
• ONE of the following: (1) Patient has another FDA-labeled indication for Empaveli and route of administration OR (2) Patient has another indication supported in compendia for Empaveli 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 as generally safe and effective (randomized, double-blind, placebo-controlled studies acceptable; case studies not acceptable)
• Non-oncology compendia allowed: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative
• Oncology compendia allowed: NCCN 1 or 2A; AHFS-DI supportive narrative; DrugDex level 1, 2A, or 2B; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; peer-reviewed medical literature

Approval duration

12 months