Sevenfact — Blue Cross Blue Shield of Texas
other FDA labeled indication or supported indication in compendia or literature (Ohio-specific coverage)
Initial criteria
- Member resides in Ohio
- 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 requested agent and route; indication supported in compendia for requested agent and route; prescriber submitted two peer-reviewed journal articles (randomized, double blind, placebo controlled clinical trials acceptable; case studies not acceptable) supporting use as generally safe and effective
Approval duration
12 months