requested Factor IX agents — Blue Cross Blue Shield of Texas
rare disease use when non-FDA labeled or alternative indication for BCBSNM or Ohio fully insured/HIM members
Initial criteria
- For BCBSNM and Ohio Fully Insured or HIM members, requested agent approved when:
- Patient has no FDA labeled contraindications
- Requested indication is a rare disease AND ONE of: (1) patient has another FDA labeled indication and route, (2) patient has indication supported in compendia (DrugDex level 1, 2A, 2B; AHFS-DI supportive text; NCCN 1 or 2A; Clinical Pharmacology supportive; LexiDrugs evidence level A), OR (3) prescriber submits two peer-reviewed journal articles demonstrating safety and efficacy (not case studies)
Approval duration
12 months