Requested hepatitis C antiviral agent (non-oncology off-label use per plan) — Blue Cross Blue Shield of Texas
Off-label indication when residing in Ohio under fully insured or HIM Shop plan
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to the requested agent
- ONE of the following: patient has another FDA labeled indication and route OR another indication supported in compendia for agent and route OR prescriber has submitted two peer-reviewed journal articles supporting proposed use as safe and effective
- Acceptable compendia: DrugDex level 1, 2A or 2B; AHFS-DI (supportive narrative); for oncology, NCCN 1 or 2A; AHFS-DI; DrugDex level 1, 2A, 2B; Clinical Pharmacology; Lexi-Drugs level A; or peer-reviewed medical literature
Approval duration
12 months