sirolimus gel 0.2% — Blue Cross Blue Shield of Texas
other FDA labeled indication or compendia-supported indication (Ohio Fully Insured or HIM Shop plans only)
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: (1) Patient has another FDA labeled indication for the requested agent and route of administration; OR (2) Patient has another indication supported in compendia (DrugDex level 1, 2A, 2B; AHFS-DI supportive); OR (3) Prescriber submitted TWO peer-reviewed journal articles supporting use as safe and effective
Approval duration
12 months