Requested agent (plan members in Ohio) — Blue Cross Blue Shield of Texas

Any FDA labeled indication or compendia/peer-reviewed supported indication for the requested agent and route

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND
Patient has no FDA labeled contraindications to requested agent AND
ONE of the following:
• Patient has another FDA labeled indication for the agent and route OR
• Indication supported in compendia (non-oncology: DrugDex level 1, 2A, 2B or AHFS-DI supportive text; oncology: NCCN 1 or 2A, AHFS-DI supportive text, DrugDex level 1, 2A, 2B, Clinical Pharmacology supportive, LexiDrugs evidence level A, or peer-reviewed literature) OR
• Prescriber submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting proposed use as safe/effective (case studies not accepted)

Continued therapy requires that indication criteria remain met; no contraindications arise

12 months