Epidiolex — Blue Cross Blue Shield of Texas

rare disease or alternative indication supported by compendia or peer-reviewed literature

Initial criteria

Request is for a BCBS NM Fully Insured or NM HIM member AND ALL of the following:
Patient does NOT have any FDA labeled contraindications to the requested agent
Requested indication is a rare disease
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 ALL of the following:
Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
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 articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective

12 months