Vanrafia (atrasentan hcl) — Blue Cross Blue Shield of Texas

Initial criteria

• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND
• Patient does NOT have any FDA labeled contraindications to the requested agent AND
• 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 for the requested agent and route of administration OR (3) Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use(s) as generally safe and effective
• Accepted study designs include randomized, double-blind, placebo-controlled clinical trials (case studies not acceptable)
• Non-oncology compendia allowed: DrugDex level 1, 2A, or 2B; AHFS-DI supportive narrative text
• Oncology compendia allowed: NCCN 1 or 2A; AHFS-DI supportive narrative text; DrugDex level 1, 2A, or 2B; Clinical Pharmacology supportive narrative text; LexiDrugs evidence level A; peer-reviewed medical literature

Approval duration

12 months