metreleptin — Blue Cross Blue Shield of Texas

FDA-labeled or compendia-supported indications for leptin deficiency or other uses

Initial criteria

Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
Patient has another FDA labeled indication for the requested agent and route of administration OR indication supported in compendia for the requested agent and route of administration OR prescriber has submitted two peer-reviewed journal articles supporting the proposed use as generally safe and effective (case studies not acceptable)
Acceptable non-oncology compendia: DrugDex level 1, 2A, or 2B; AHFS-DI (supportive narrative)
Acceptable oncology compendia: NCCN 1 or 2A; AHFS-DI (supportive narrative); DrugDex level 1, 2A, or 2B; Clinical Pharmacology (supportive narrative); LexiDrugs level A; peer-reviewed medical literature

12 months