Tryvio — Blue Cross Blue Shield of Texas

other FDA labeled indication

Initial criteria

BCBS NM Fully Insured or NM HIM member requests approved when ALL of the following:
1. The patient does NOT have any FDA labeled contraindications to the requested agent AND
2. The requested indication is a rare disease AND
3. ONE of the following:
A. The patient has another FDA labeled indication for the requested agent and route of administration OR
B. The patient has another indication that is supported in compendia for the requested agent and route of administration
OR
Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND ALL of the following:
1. The patient does NOT have any FDA labeled contraindications to the requested agent AND
2. ONE of the following:
A. The patient has another FDA labeled indication for the requested agent and route of administration OR
B. The patient has another indication that is supported in compendia for the requested agent and route of administration OR
C. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting proposed use(s) as generally safe and effective (case studies not acceptable)

12 months