miglustat — Blue Cross Blue Shield of Texas

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
• Patient has no FDA-labeled contraindications to requested agent
• ONE of the following: (a) patient has another FDA-labeled indication for agent and route; OR (b) patient has another indication supported in compendia; OR (c) prescriber submitted two peer-reviewed journal articles supporting use as generally safe and effective (randomized, double blind, placebo-controlled acceptable; case studies not acceptable)
• Accepted non-oncology compendia: DrugDex level 1, 2A, 2B; AHFS-DI (supportive narrative)
• Accepted oncology compendia: NCCN 1 or 2A; AHFS-DI (supportive text); DrugDex level 1, 2A, 2B; Clinical Pharmacology (supportive text); LexiDrugs level A; or peer-reviewed literature

Reauthorization criteria

• Patient previously approved through plan’s Prior Authorization process
• Patient has had clinical benefit with requested agent

Approval duration

12 months