requested agent — Blue Cross Blue Shield of Texas
patient residing in Ohio under Fully Insured or HIM Shop (SG) plan with other FDA/compendia supported use
Initial criteria
- Member resides in Ohio
- Plan is Fully Insured or HIM Shop (SG)
- Patient does not have any FDA labeled contraindications to requested agent
- One of the following: (1) patient has another FDA labeled indication for requested agent and route of administration OR (2) patient has another compendia-supported indication for requested agent and route OR (3) prescriber has submitted two peer-reviewed journal articles demonstrating safe and effective use per required standards
Approval duration
12 months