Filsuvez — Blue Cross Blue Shield of Texas

rare disease

Initial criteria

Request is for 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
Patient has another FDA labeled indication for the requested agent and route of administration OR has another indication supported in compendia for the requested agent and route of administration
Alternatively, member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient does NOT have any FDA labeled contraindications AND one of the following is met:
Patient has another FDA labeled indication for the requested agent and route of administration OR has another indication supported in compendia for the requested agent and route of administration OR prescriber has submitted TWO articles from major peer-reviewed medical journals supporting proposed use as safe and effective; accepted designs include randomized, double-blind, placebo-controlled trials; case studies are not acceptable

12 months