growth hormone agents (non-specified) — Blue Cross Blue Shield of Texas
off-label indications with peer-reviewed evidence
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (Small Group)
- No FDA labeled contraindications
- One of: another FDA labeled indication for requested agent and route; compendia-supported indication; OR two peer-reviewed journal articles supporting proposed use as generally safe and effective (case studies not acceptable)
Approval duration
12 months