satralizumab-mwge — Blue Cross Blue Shield of Texas
other FDA labeled or compendia supported indications (member resides in Ohio; plan Fully Insured or HIM Shop)
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 for the agent and route OR patient has another indication supported in compendia for the agent and route OR prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective (excluding case studies)
- Acceptable non-oncology compendia: DrugDex level 1, 2A, 2B; AHFS-DI (narrative text supportive)
- Acceptable oncology compendia: NCCN 1 or 2A; AHFS-DI; DrugDex level 1, 2A, 2B; Clinical Pharmacology (narrative text supportive); LexiDrugs evidence level A; peer-reviewed literature
Approval duration
12 months