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

rare disease indications

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

12 months