fecal microbiota spores, live-brpk caps — Blue Cross Blue Shield of Texas

rare disease use for BCBS NM Fully Insured or NM HIM member

Initial criteria

For BCBS MT Fully Insured or MT HIM member: A. Patient age <18 years; B. No FDA labeled contraindications; C. Indication supported in TWO peer-reviewed journal articles as generally safe and effective; D. Support for age bracket (infancy, childhood, adolescence) in TWO peer-reviewed journal articles as generally safe and effective
For BCBS NM Fully Insured or NM HIM member: A. No FDA labeled contraindications; B. Requested indication is a rare disease; C. ONE of the following: 1. Patient has another FDA labeled indication for the requested agent and route OR 2. Indication supported in compendia for the requested agent and route
For Ohio Fully Insured or HIM Shop (SG) member: A. Member resides in Ohio; B. No FDA labeled contraindications; C. ONE of the following: 1. Patient has FDA labeled indication for requested agent and route OR 2. Indication supported in compendia for requested agent and route OR 3. Prescriber has submitted TWO peer-reviewed journal articles supporting proposed use as generally safe and effective

12 months