marstacimab-hncq — Blue Cross Blue Shield of Texas

Off-label indications for BCBS MT Fully Insured/HIM members or NM/Ohio exceptions per policy

Initial criteria

Request for BCBS MT Fully Insured or MT HIM member AND:
Patient age <18 years AND no FDA labeled contraindications AND
Indication supported in TWO major peer-reviewed medical journal articles as generally safe and effective (not case studies) AND
Support for patient's age bracket (infancy, childhood, adolescence) in same literature
OR Request for BCBS NM Fully Insured or NM HIM member AND:
No FDA labeled contraindications AND requested indication is a rare disease AND
Patient has another FDA labeled or compendia-supported indication OR
Two peer-reviewed journal articles support use as generally safe and effective (not case studies)
OR request for Ohio Fully Insured or HIM Shop member AND same journal/comprendia criteria

BCBSOK: 36 months; all other: 12 months