Drug Indications (Medicaid Expansion)

Policy ID: ME-I-9002-003-05

Section: Injections

Effective Date: January 01, 2022

Revised Date: May 06, 2025

Revision Effective Date: July 01, 2025

Last Reviewed: May 13, 2025

Applies To: Medicaid Expansion Only

Description

Blue Cross Blue Shield of North Dakota recognizes the following drug compendium as authoritative sources for use in the determination of a medically-accepted indication of drugs and biologicals used off-label. New uses for approved products that are not reflected in a product's labeling are often discovered after marketing. Before a pharmaceutical manufacturer may include any new indications in the labeling for a particular drug it must obtain the government's approval for the uses. Such approval requires the completion of adequate and well-controlled clinical trials to document the drug's safety and efficacy for the new uses. Manufacturers, in some cases, may not seek or obtain approval of new uses since there may not be sufficient economic incentive for the product sponsor to perform the necessary research or to make application to the regulatory agency.

Merative^TM Health Micromedex®
Reviewed by international experts, DRUGDEX evidence-based documents cover FDA-approved and investigational prescription and nonprescription drugs, as well as non-U.S. preparations.
National Comprehensive Cancer Network
The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 33 of the world's leading cancer centers devoted to patient care, develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

If a medical policy specific to an agent does not exist:

The use of all agents must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route). Merative 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 recommendations. Benefits will be allowed for either Accepted FDA approved recommendations or Accepted off-label recommendations from either of these sources. The Micromedex Strength of Recommendation of at least Class IIb AND a level of Efficacy Rating of at least IIa will be considered an allowable indication for off-label indications. NCCN Guidelines with a Category 2B level of evidence and consensus or above will be considered an allowable indication for off-label use.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 5-24-2022

Updated criteria statement based off of new language in Version 2022.3 of the PDL

Internal Medical Policy Committee 5-23-2023 Annual review,

Updated Micromedex name from IBM Watson to Merative and
Updated NCCN description

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Annual review no clinical content change

Internal Medical Policy Committee 5-13-2025 Effective July 01, 2025

Annual review no clinical content change

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: ME-I-9002-003-04

Section: Injections

Effective Date: January 01, 2022

Revised Date: May 08, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: June 30, 2025

Applies To: Medicaid Expansion Only

Description

Merative^TM Health Micromedex®
Reviewed by international experts, DRUGDEX evidence-based documents cover FDA-approved and investigational prescription and nonprescription drugs, as well as non-U.S. preparations.
National Comprehensive Cancer Network
The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 33 of the world's leading cancer centers devoted to patient care, develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

If a medical policy specific to an agent does not exist:

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 5-24-2022

Updated criteria statement based off of new language in Version 2022.3 of the PDL

Internal Medical Policy Committee 5-23-2023 Annual review,

Updated Micromedex name from IBM Watson to Merative and
Updated NCCN description

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Annual review no clinical content change

Medical Policies Quick Search

Drug Indications (Medicaid Expansion)

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer