Emrosi — Blue Cross Blue Shield of Texas

Initial criteria

• ALL of the following: (1) The member resides in Ohio AND (2) The plan is Fully Insured or HIM Shop (SG) AND (3) The patient does NOT have any FDA labeled contraindications to the requested agent AND (4) ONE of the following: (A) The patient has another FDA labeled indication for the requested agent and route of administration OR (B) The patient has another indication supported in compendia (DrugDex level 1, 2A or 2B; AHFS-DI supportive narrative; NCCN 1 or 2A; Clinical Pharmacology supportive narrative; LexiDrugs evidence level A; peer-reviewed medical literature) OR (C) The prescriber has submitted two peer-reviewed journal articles supporting safe and effective use.

Reauthorization criteria

• Reauthorization requires continued medical necessity, absence of contraindications, and documentation that criteria remain met.

Approval duration

BCBSOK 36 months; others 12 months