Rayos — Blue Cross Blue Shield of Texas

Initial criteria

• 1. The member resides in Ohio AND
• 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. 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 supported in compendia for the requested agent and route OR
• 3. The prescriber provides TWO peer-reviewed journal articles (JAMA, NEJM, Lancet, etc.) supporting proposed use as safe and effective. Case studies not accepted [journal articles required]

Approval duration

12 months