Furoscix — Blue Cross Blue Shield of Texas

Initial criteria

• The request is for a BCBS NM Fully Insured or NM HIM member and ALL of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. The requested indication is a rare disease AND
• C. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• For members residing in Ohio with Fully Insured or HIM Shop (SG) plan ALL of the following:
• A. The member resides in Ohio AND
• B. The plan is Fully Insured or HIM Shop (SG) AND
• C. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• D. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (case studies not acceptable)
• Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI supportive narrative
• Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI supportive narrative, DrugDex level 1, 2A, or 2B, or Clinical Pharmacology supportive narrative, LexiDrugs evidence level A, peer-reviewed medical literature

Approval duration

12 months