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.
