fezolinetant — Blue Cross Blue Shield of Texas
other FDA labeled or compendia-supported indications (Ohio Fully Insured or HIM Shop plans)
Initial criteria
- The member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: (1) No FDA labeled contraindications to the requested agent AND (2) ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route OR (2) Patient has another indication supported in compendia for the requested agent and route OR (3) Prescriber has submitted TWO peer-reviewed journal articles supporting proposed use as generally safe and effective (major journals such as JAMA, NEJM, Lancet; randomized, double-blind, placebo-controlled acceptable; case studies not acceptable). Compendia allowed: DrugDex level 1, 2A, 2B; AHFS-DI supportive text; for oncology, also NCCN 1 or 2A, Clinical Pharmacology, LexiDrugs evidence level A, peer-reviewed medical literature supportive).
Approval duration
12 months