Sporanox (itraconazole) capsules — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following:
• 1. For BCBS NM Fully Insured or NM HIM member AND ALL of the following:
• A. Patient does NOT have any FDA labeled contraindications AND
• B. Requested indication is a rare disease AND
• C. ONE of the following:
• 1. Patient has another FDA labeled indication for requested agent and route OR
• 2. Patient has another indication supported in compendia for the requested agent and route OR
• 2. ALL of the following:
• A. Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND
• B. Patient does NOT have any FDA labeled contraindications AND
• C. ONE of the following:
• 1. Patient has another FDA labeled indication for requested agent and route OR
• 2. Patient has another indication supported in compendia for requested agent and route OR
• 3. Prescriber has submitted TWO articles from major peer-reviewed professional medical journals (JAMA, NEJM, Lancet, etc.) supporting use as safe and effective [case studies not acceptable]
• Non-oncology compendia: DrugDex level 1, 2A, or 2B, AHFS-DI (supportive narrative)
• Oncology compendia: NCCN 1 or 2A, AHFS-DI, DrugDex level 1, 2A, or 2B, Clinical Pharmacology (supportive), LexiDrugs evidence level A, peer-reviewed medical literature

Approval duration

12 months