migalastat hcl — Blue Cross Blue Shield of Texas

Initial criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• 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 peer-reviewed journal articles supporting the proposed use(s) as generally safe and effective (case studies not acceptable)
• Accepted compendia: DrugDex level 1, 2A, or 2B; AHFS-DI (supportive); oncology-specific sources per NCCN 1 or 2A, AHFS-DI, DrugDex level 1, 2A, or 2B, Clinical Pharmacology (supportive), or LexiDrugs evidence level A

Approval duration

12 months