Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
If a medical policy specific to a drug does not exist:
IBM Watson Health Micromedex® or the National Comprehensive Cancer Network (NCCN) Guidelines can be used as a reference to determine FDA approval of a drug or accepted, off-label indications. Benefits will be allowed for either Accepted FDA approved indications or Accepted off-label indications from either of these sources. The Micromedex Strength of Recommendation Class I or Class IIa will be considered an allowable indication for off-label indications. NCCN Guidelines with a Category 2A level of evidence and consensus or above will be considered an allowable indication for off-label use.
