sacrosidase — Blue Cross Blue Shield of Texas
Other FDA labeled or compendia-supported indications (Ohio Fully Insured or HIM Shop plans)
Initial criteria
- The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
- The patient does NOT have any FDA labeled contraindications to the requested agent
- 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 of administration OR (3) The prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use(s) as generally safe and effective
Approval duration
12 months