Voxzogo — Blue Cross Blue Shield of Texas

Initial criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has an indication supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO peer-reviewed medical journal articles demonstrating the proposed use is safe and effective (acceptable designs include randomized, double-blind, placebo-controlled clinical trials; case studies not accepted)
• Non-oncology compendia accepted: DrugDex level 1, 2A, or 2B; AHFS-DI (narrative supportive)
• Oncology compendia accepted: NCCN 1 or 2A; AHFS-DI (narrative supportive); DrugDex level 1, 2A, 2B; Clinical Pharmacology (narrative supportive); LexiDrugs evidence level A; peer-reviewed medical literature

Approval duration

12 months