Rayos — Blue Cross Blue Shield of Texas

FDA labeled indications

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]

12 months