DISCLAIMER OFF-LABEL DRUG USE. Subject: Off-Label Use of Drugs and Biologic Agents Original Effective Date: 12/11/13

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1 Subject: Off-Label Use of Drugs and Biologic Agents Original Effective Date: 12/11/13 Policy Number: MCP-162 Revision Date(s): 6/13/14; 5/8/15; 7/10/2018 Review Date(s): 12/15/2016; 6/22/2017, 7/10/2018 DISCLAIMER This Molina Clinical Policy (MCP) is intended to facilitate the Utilization Management process. It expresses Molina's determination as to whether certain services supplies are medically necessary, experimental, investigational, cosmetic f purposes of determining appropriateness of payment. The conclusion that a particular service supply is medically necessary does not constitute a representation warranty that this service supply is covered (i.e., will be paid f by Molina) f a particular member. The member's benefit plan determines coverage. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusion(s) other benefit limitations applicable to this service supply. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government CMS f Medicare and Medicaid members. CMS's Coverage Database can be found on the CMS website. The coverage directive(s) and criteria from an existing National Coverage Determination (NCD) Local Coverage Determination (LCD) will supersede the contents of this MCP document and provide the directive f all Medicare members. OFF-LABEL DRUG USE A. The U.S. Food and Drug Administration (FDA) approves drugs f specific indications that are included in the drug s labeling after proven to be safe and effective through review of suppting well-designed clinical trials. B. FDA approved indication is an indication (diagnosis, illness, injury, syndrome, condition f which a drug may be given) on the official label of the pharmaceutical agent with prescribing instructions, which includes, but is not necessarily limited to, dosage, route of administration, duration and frequency of administration and population to whom the drug would be administered. The approved indications identify the specific disease states that the agent has been shown to be safe, efficacious and meet all clinical requirements set fth by the FDA. C. Off-label (also referred to as unlabeled non-fda-approved) drug use refers to the prescription of licensed drugs f clinical indications in a manner different from that approved by the US Food and Drug Administration (FDA) and thus not included in the official FDA-approved labeling f the agents. Off-label drug use takes many fms, and versions of it occur in countries outside of the United States as well. Use of drugs f a clinical indication, in a patient population, through a route of administration, with a dose not specified in the FDA-approved labeling can all be considered off label. A 2006 study in the Archives of Internal Medicine estimates that 21 percent of commonly used drugs are prescribed f off-label uses. Requests f coverage of medications devices that are non-fda approved off-label will be considered on a case-by-case basis. Page 1 of 12

2 D. Determinations of coverage f an off-label use of a drug may be considered under ANY of the following circumstances: A single case exception to current coverage policies, due to unique circumstances Until relevant coverage policies undergo full review, revision and approval by the Molina Clinical Policy Committee (MCPC) Molina Healthcare National P&T Committee In the absence of a coverage policy currently addressing the drug the requested use of the drug POSITION STATEMENT Molina Clinical Policy (MCP) criteria drug-specific approved policies take precedence over the criteria in this policy; hence these drug-specific policies must be reviewed pri to applying the criteria in this policy. This policy should only be applied when there is no MCP ( drug-specific policy) addressing the requested off-label use of an FDA-approved drug. This policy shall not be interpreted to require coverage f any drug biological agent when the FDA has determined its use to be contraindicated. Molina Healthcare will evaluate each request f an unlabeled use of any drug on a caseby-case basis. The FDA approves drugs f specific indications that are included in the drug's labeling. When a drug is used f an indication other than those specifically included in the labeling, it is referred to as an off-label use. FDA indication alone does not establish the medical necessity of a particular drug f a particular patient. Molina Healthcare reserves the right to review all treatments f their clinical appropriateness. If there is a discrepancy between this policy and the plan of benefits, the provisions of the member s benefits plan will govern. Accepted Standard of Medical Practice: Acceptance by individual health care practitioners, even a limited group of health care practitioners, does not translate to general acceptance by the medical community. Testimonials, recommendations, and declarations indicating such limited acceptance and limited case studies are not sufficient evidence of general acceptance by the medical community Molina Healthcare reserves the right to update the content any ption of this policy, as well as any Molina Clinical Policy (MCP) and coverage criteria, to include omit any off-label condition(s) as necessary based on medical literature and clinical studies that may become available. Molina Healthcare will continue to review clinical evidence related to this policy and may revise this policy based upon the development of the published clinical evidence. Page 2 of 12

3 EVIDENCE BASED REVIEW Centers f Medicare & Medicaid Services (CMS) The coverage directive(s) and criteria from an existing National Coverage Determination (NCD) Local Coverage Determination (LCD) will supersede the contents of this Molina Molina Clinical Policy (MCP) document and provide the directive f all Medicare members. The directives from this MCP document may be followed if there are no available NCD LCD documents available and outlined below. F Molina Medicare members, refer to the Preferred Pri Authization Criteria below and available at: The Centers f Medicare & Medicaid Services (CMS) Medicare Benefit Policy; Pub Transmittal 96, defines compendium as a comprehensive listing of FDA-approved drugs and biologicals a comprehensive listing of a specific subset of drugs and biologicals in a specialty compendium. A compendium: (1) includes a summary of the pharmacologic characteristics of each drug biological and may include infmation on dosage, as well as recommended endsed uses in specific diseases; (2) is indexed by drug biological; and (3) effective January 1, 2010, pursuant to section 182(b) of the Medicare Improvements f Patients and Providers Act (MIPPA), has a publicly transparent process f evaluating therapies and f identifying potential conflicts of interests. The following are currently the authitative compendia f CMS approved clinical decision suppt tools to determine medically-accepted indication of off-label use: 1. American Hospital Fmulary Service-Drug Infmation (AHFS-DI) 2. National Comprehensive Cancer Netwk (NCCN) Drugs and Biologics Compendium 3. Truven Micromedex DrugDex Compendium (DrugDex) [Success to USP-DI] 4. Elsevier Gold Standard s Clinical Pharmacology Compendium (Clinical Pharmacology) 5. Wolters Kluwer Lexi-Drugs (Lexi-Drugs) Standard Drug Reference Compendia Compendia (compendiums) is defined by Medicare as a comprehensive listing of FDA-approved drugs and biological a comprehensive listing of a specific subset of drugs and biological in a specialty compendium, f example, a compendium of anti-cancer treatment. In this revised definition, a compendium: 1. Includes a summary of the pharmacologic characteristics of each drug biological and may include infmation on dosage, as well as recommended endsed uses in specific diseases; 2. Is indexed by drug biological; and 3. Has a publicly transparent process f evaluating therapies and f identifying potential conflicts of interests. The following resources/references are considered acceptable and utilized by Molina Healthcare to determine medical necessity criteria based on the best available clinical evidence to suppt safety and efficacy. The der of these resources as listed below represents the hierarchy of evidence. A. Applicable Federal State mandates and guidelines Medicare Hierarchy: 1. National Coverage Determinations 2. Local Coverage Determinations Search f LCD developed in state where health plan is located Follow hierarchy path below if state LCD is not available NCD s LCD s that are silent on medical necessity directives require the next level of hierarchy to obtain the medical necessity directive Page 3 of 12

4 B. Cpate policy documents addressing new existing technology C. Approved clinical decision suppt tools to determine medically-accepted indication of off-label use: 1. American Hospital Fmulary Service-Drug Infmation (AHFS-DI) 2. National Comprehensive Cancer Netwk (NCCN) Drugs and Biologics Compendium 3. Truven Micromedex DrugDex Compendium (DrugDex) [Success to USP-DI] Indications that DrugDex lists as Class I, Class IIa Class IIb recommendations and/ efficacy will be considered medically accepted indications f the purposes of determining coverage policy. Indications that DrugDex lists as Class III recommendations and/ efficacy will not be considered medically accepted indications f the purposes of determining coverage policy. 4. Elsevier Gold Standard s Clinical Pharmacology Compendium (Clinical Pharmacology) 5. Wolters Kluwer Lexi-Drugs (Lexi-Drugs) Evaluation of Off-label Requests Molina Medical Reviewers/Staff, in addition to utilizing the above references with the hierarchy of evidence listed in this Evidence Based Review section to evaluate a request f an off-label use, also considers/weighs the following facts based on the clinical literature [submitted by requesting Prescriber]: Submitted peer-reviewed literature* by requesting Prescriber *Peer-Review Medical Literature: Off-label uses that are suppted by clinical research peer-reviewed medical literature that may appear in scientific, medical, and pharmaceutical publications in which iginal manuscripts are published, only after having been critically reviewed f scientific accuracy, validity, and reliability by unbiased, independent experts pri to publication. Availability of published repts of well-designed and well-conducted investigations published in peer-review journals Assessment of the quality and level of evidence reflected in published repts and systematic reviews Opinions and evaluations by national medical associations, consensus panels, other technology evaluation bodies are evaluated accding to the scientific quality of the suppting evidence and rationale Absence of potential clinically imptant concerns about the drug/biologic such as increased toxicity with no substantial therapeutic gain Positive therapeutic perspective as reflected by clinical evidence, expert opinion, best practices, and/ authitative guidelines Evidence of improved risk-to-benefit ratios (including compliance) relative to existing therapeutic alternatives The imptance and severity of the disease Availability of alternative therapies and their relative toxicities, the number of patients affected by the disease, other patient population considerations (e.g., age, gender, pharmacogenomics), and other facts (e.g., cost and economic considerations) also are imptant considerations. Page 4 of 12

5 COVERAGE DETERMINATIONS FOR OFF-LABEL DRUG/BIOLOGIC AGENT REQUESTS In the absence of a Molina Clinical Policy pri authization criteria addressing the requested off-label use of the drug biologic, requests will be reviewed on a case-by-case basis. Molina Healthcare may authize coverage of the requested off-label use drug biologic if ALL of the following criteria are met: [ALL] Requested drug has been approved by the U.S. Food and Drug Administration (FDA) f at least ONE indication NOTE: Medications and vaccines that have not received final FDA marketing approval f any indication are considered investigational. Orphan designation is not synonymous to FDA-approval and phan drug status has no significance in the evaluation of off-label treatments. An phan drug is one that is used f the treatment of a rare disease condition that either occurs in fewer than 200,000 individuals in the US is me prevalent but f which there is no reasonable expectation that the cost of developing and marketing the drug in the US f such disease condition would be recovered from US sales. The phan drug designation is independent from marketing approval status and may apply to medications that are either approved unapproved f marketing. F the purposes of this policy, phan drug status has no significance in the evaluation of off-label treatments. Prescribed f the treatment of a life-threatening, chronic, and seriously debilitating conditions as defined by ONE of the following: [ONE] Life-threatening is defined as either both of the following: [AT LEAST ONE] 1) Diseases conditions where the likelihood of death is high unless the course of the disease is interrupted 2) Diseases conditions with potentially fatal outcomes, where the end point of clinical intervention is survival Chronic and seriously debilitating is defined as diseases conditions that require ongoing treatment to maintain remission prevent deteriation and cause serious long-term mbidity No other treatment options are available f member s condition/illness. Submission of clinical rationale demonstrating there are no established treatments recommended alternatives [Documentation required] OR Member has contraindications has failure to all established therapies and alternative treatments that are FDAapproved requested indication [Documentation required] Requested drug is not contraindicated by the FDA f the off-label use prescribed Page 5 of 12

6 Requested drug is documented as appropriate f the stated usage by ONE of the following CMS approved drug compendia: [ONE] FDA Orphan Drug Approval Website Medications and vaccines that have not received final FDA marketing approval f any indication are considered investigational. Orphan designation is not synonymous to FDA-approval and phan drug status has no significance in the evaluation of off-label treatments. An phan drug is one that is used f the treatment of a rare disease condition that either occurs in fewer than 200,000 individuals in the US is me prevalent but f which there is no reasonable expectation that the cost of developing and marketing the drug in the US f such disease condition would be recovered from US sales. The phan drug designation is independent from marketing approval status and may apply to medications that are either approved unapproved f marketing. F the purposes of this policy, phan drug status has no significance in the evaluation of off-label treatments. Elsevier Gold Standard s Clinical Pharmacology The narrative text is supptive of the requested off-label use and noted as a Strong Recommendation. Recommendations noted as Equivocal/Weak are not considered supptive of an off-label indication. Molina page access URL: American Hospital Fmulary Service-Drug Infmation (AHFS-DI): The narrative text in American Hospital Fmulary Service--Drug Infmation (AHFS-DI) is supptive of the requested off-label use. NOTE: The "dagger" symbol is used to indicate off-label drug use by the American Hospital Fmulary Service Drug Infmation (AHFS, Bethesda, MD). If AHFS indicates an off-label use, but qualifies that statement with "but additional study is needed" "further study is needed to evaluate safety and efficacy", the qualifying language does not suppt an off-label indication as medically necessary. -Refer to Appendix 3 f AHFS Levels of Evidence Rating System Molina page access URL: AHFS Drug Infmation: National Comprehensive Cancer Netwk Compendium (NCCN) MHI recognizes Categy 1 and 2 A approvals NOTE: The complete absence of narrative text on a use is considered neither supptive n non-supptive. OR Prescriber submitted copies of relevant full-text articles from at least two (2) maj peer-reviewed journals* providing evidence of both safety and efficacy f the off-label requested use and meets ALL of the following: [ALL] Phase III randomized-placebo controlled studies with subject size sufficient to determine statistical validity [Published studies required] An adequate number of well-designed studies with sufficient numbers of subjects in relation to the incidence prevalence of the disease [MCP-000] Page 6 of 12

7 NOTE: *Peer-Review Medical Literature: Off-label uses that are suppted by clinical research peer-reviewed medical literature that may appear in scientific, medical, and pharmaceutical publications in which iginal manuscripts are published, only after having been critically reviewed f scientific accuracy, validity, and reliability by unbiased, independent experts pri to publication. Molina Healthcare considers any drug being studied in a phase I phase II clinical trial, use that is based solely on evidence from a phase I phase II clinical trial, investigational. All submitted studies must be published Phase III randomized-placebo controlled studies with subject size sufficient to determine statistical validity. Refer to Appendix 2: Clinical Trial Phases f Investigational New Drugs Published in the regular editions of the journals that publish iginal manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts f scientific accuracy, validity, and reliability NOTE If ANY of the below are met, evidence is considered insufficient. Articles submitted must not be in the fm of: [EXCLUSION CRITERIA if ANY are met] o A special supplement publication and not to include publications privately funded by parties (i.e. manufacturers of the product) with a vested interest in the recommendations and provides full disclosure of any conflict of interest biases f all auths, contributs, edits associated with the journal ganization o In-house publications by pharmaceutical manufacturing companies abstracts (including meeting abstracts) are not considered peer review medical literature o Retrospective studies, opinion statements, case repts, letters to the edit, abstracts of a publication, repts of Phase I Phase II trials are not sufficient In general, case repts are considered uncontrolled, are based on anecdotal infmation, and do not provide adequate supptive clinical evidence f determining accepted uses of drugs. Disease improvements must be attainable in clinical practice outside of the investigational/research setting [MCP-000] Drug biologic has all of the following outcomes [MCP-000] A substantial probability of clinical benefit; and Improve the net health outcome as much as, me than, established alternatives (as demonstrated by reduction in mtality, mbidity, and signs and symptoms) Prescriber must submit member s medical recds and other relevant documentation as deemed necessary by Molina Healthcare to determine if an off-label use is reasonable and necessary f treatment of a member s condition disease. NOTE: It is the responsibility of the prescribing physician to submit to Molina Healthcare documentation suppting the proposed off label use uses, as requested. Otherwise, the request may be denied due to inadequate incomplete infmation. Page 7 of 12

8 LIMITATIONS OF COVERAGE If the requested off-labeled use does not meet ANY of the criteria in the above Coverage Determination f Off- Label Drug/Biologic Requests section, such as (including but not limited to the following): 1) determined to be not indicated by the Centers f Medicare and Medicaid Services (CMS), 2) contraindicated unsuppted by the Food and Drug Administration (FDA), 3) if the use is identified as not indicated by one of the above listed compendiums, 4) if the use is determined not safe and effective based on peer-reviewed medical literature, Then the off-labeled use will be considered by Molina Healthcare as not meeting the reasonable and necessary threshold, and therefe will not be authized f coverage. Regardless of the suppting evidence f coverage f an off-labeled use of a drug, authization f coverage is only authized based upon the criteria stated in this policy by Molina Healthcare. If member meets ALL of the above criteria f the requested off-label use, the following may be applicable with the authization f coverage, as deemed appropriate by Medical Reviewer: [ANY] Recommendation of fmulary alternative(s), unless contraindicated, which is: [ANY] FDA-approved f the requested use/indication, Recommended accepted by treatment guidelines listed in any compendia, considered standard of care, as a treatment option of equal greater efficacy compared to the requested drug/regimen, Use of an accepted non-pharmacologic interventions of equal greater efficacy Quantity limits: In accdance to member s plan benefits Initial authization period: Limited to the time required to evaluate and establish clinical benefit. This time period is dependent on the drug/regimen being requested and the condition being treated. Continuation of coverage requests: Member must demonstrate positive response(s) to therapy that indicate effectiveness, including but not limited to reduction in mtality, mbidity, and signs and symptoms [Documentation required] Page 8 of 12

9 EXCLUSIONS Coverage will not be provided f off-label usage unless pri authization request meets ALL criteria defined in the above applicable section. Off-label drugs are not covered when the following circumstances are applicable: [ANY] Requested use, regardless of medical necessity, is specifically excluded from coverage in a member s plan benefit Pharmaceutical agents (and vaccines) that have not received final FDA marketing approval f any indication has not been fully licensed approved by the FDA are considered investigational and coverage will not be authized Use is identified as not indicated by CMS (in the case of Medicare members) the FDA Use is specifically identified as not indicated in at least one of the maj compendia Use is determined (based on peer-reviewed literature) that the drug is not safe and effective Use of a product with only an phan drug designation and without FDA marketing approval An "phan drug" is a product that treats a rare disease (e.g., affecting fewer than 200,000 Americans). Products have FDA phan drug approval when they meet the phan drug designation and marketing criteria established by the FDA. Reference: U.S. Food and Drug Administration (FDA). Developing Orphan Products: FDA and Rare Disease Day. Last updated February 27, Available at: Use of any drug when the FDA has determined that use to be contraindicated Note: Services related to non-covered services are not covered (e.g., administration services) INDEPENDENT REVIEW ORGANIZATIONS Molina Healthcare clinical reviewers staff submitting case reviews to an independent review ganization [such as Advanced Medical Review (AMR)] shall review the reference materials provided f decision-making. Independent review reference materials which do not meet the requirements shall be routed back to the independent review ganization and the following should be requested: [MCP-000] An explanation of the clinical rational and relevant, current evidence used to suppt the decision shall be requested to be reviewed by both the independent review quality check process and the oversight physician at the ganization Independent review ganization to provide an assessment of the quality of evidence utilized by the Peer Reviewer to perfm the review Reviews deemed of insufficient quality shall be requested to be re-reviewed at the expense of the independent review ganization Page 9 of 12

10 APPENDIX APPENDIX 1: Hayes Technology Assessments Rating Hayes technology assessments assign a rating f each topic reviewed. The rating scale is from A to D f regular repts and A through D2 f Genetic Testing. The scale reflects the strength of the evidence in terms of safety, efficacy, impact on health outcomes, indications f use, patient selection criteria and technology comparisons. The infmation outlined below summarizes each rating and provides Molina staff direction on coverage decision making: A- High level of evidence suppting safety and efficacy. FDA approval but not always f the specific clinical application. Coverage Recommendation: Approve f use under recommended guidelines unless it is a noncovered state plan benefit such as f cosmetic purposes if an existing Molina Clinical Policy provides an alternative directive. B- Moderate level of evidence regarding safety and efficacy. Further research needed to clarify issues reviewed. FDA approval but not always f the specific clinical application. Coverage Recommendation: Approve f use under recommended guidelines unless it is a non-covered state plan benefit such as f cosmetic purposes if an existing Molina Clinical Policy provides an alternative directive. C- Some positive evidence of safety and efficacy. Health outcome benefit has not been proven due to conflicting sparsity of data. Coverage Recommendation: Medical Direct review is required with a peer to peer discussion between the Plan Medical Direct and the requesting physician in der f coverage to be approved. Recommend consideration of alternative treatments. Coverage considerations f approving in this categy are based upon available Policy documents approved by the Molina Clinical Policy Committee following a review of evidence from other sources in addition to Hayes. Coverage may also be provided when all other conventional treatment options have been exhausted and there is reasonable evidence to suppt the technology could prolong the life of the member, reste physical and/ social functioning benefit the member significantly enough that the benefits outweigh any risks to the member. Unique circumstances approved by a plan should be accompanied by well controlled prospective coht/comparison studies published and referenced in medical scientific literature with relevant clinical evidence suppting the assertion that the requested modality would provide benefit to the member and a clinical advantage over its competits, two independent studies are preferred. D, D1, D2- No evidence to suppt the safety and efficacy benefits of the treatment technology. Coverage Recommendation: Consider and treat as an experimental and investigational procedure. Coverage may be provided in this categy if the Molina Clinical Policy Committee has obtained and reviewed infmation from other sources and has approved f coverage. New studies provided should be reviewed in accdance with MCP-000 Evaluation of New and Existing Technologies Including Experimental and Investigational Designations Experimental/Investigational guidelines Page 10 of 12

11 APPENDIX 2: Clinical Trial Phases f Investigational New Drugs Clinical trial phases f Investigational New Drugs are defined by the FDA as follows: Phase 1 trials are concerned primarily with determining dosing, documenting how a drug is metabolized and excreted and identifying acute side effects. A small number of healthy volunteers (between 20 and 80) are evaluated in Phase 1 trials. Phase 2 trials involve approximately 100 to 300 participants who have the disease condition that the product could treat. Researchers seek to gather further safety data and preliminary evidence of the drug's efficacy, and they develop and refine research methods f future trials. Drugs showing effectiveness with little risks identified will move to Phase 3. Phase 3 trials include a population of patients between 1,000 to 3,000 with a disease. This phase further tests the product's effectiveness, monits side effects, and compares the product's effects to a standard treatment, when available. Phase IV trials are conducted after a product is already approved and on the market to identify potential long-term risks, benefits, and optimal use, to test the product in different populations of people, such as children. APPENDIX 3: AHFS Levels of Evidence Rating System Available at: Evidence Level Level 1: High strength/ Quality Evidence consists of at least one randomized, double-blind trial without imptant limitations (i.e., large treatment effect); intent-to-treat analysis used, confidence intervals repted. If one me than one trial is available, these trials have consistent results A meta-analysis of such trials with consistent results (i.e., low heterogeneity) Evidence consisting of a non-blinded single-blinded trial that meets study objective endpoints may be considered as Level 1 evidence in some cancer-related cases (i.e. sponsed cooperative group study a multicenter trial) Level 2: Moderate Strength/Quality Evidence consists of at least one non-blinded single-blinded, randomized clinical trial Evidence consists of at least one non-blinded single-blinded, non-randomized clinical trial A meta-analysis of randomized, controlled clinical trials with heterogeneous results if reasons f heterogeneity in individual trials are adequately discussed Evidence consists of at least one randomized, controlled clinical trial, but with methodological limitations (e.g. large number of patients lost to follow-up and no intent to-treat analysis and/ imptant data not recded) Evidence is inconsistent (i.e., two me randomized controlled trials with unexplained, widely varying estimates of treatment effects, even if results of individual trials would constitute a strong Level 1 evidence when considered alone) Evidence consisting of a non-blinded, non-randomized trial (e.g., a phase II study) may be considered as Level 2 in some cancer-related cases (e.g., rare cancers cancers with limited available treatment options) Page 11 of 12

12 Level 3: Low Strength/Quality Evidence consists of observational studies, case repts case series; may also include randomized-clinical trials with multiple serious deficiencies study limitations. Level 4: Opinion/Experience Expert consensus panel repts expert reviewer s comments AHFS Grades of Recommendation A: Recommended-- Accepted (e.g., should be used, is recommended, is useful/effective/beneficial in most cases) B: Reasonable Choice (Accepted, with Possible Conditions) (e.g., option) (e.g., is reasonable to use in certain subgroups clinical scenarios) C: Not Fully Established (Unclear risk/benefit, equivocal evidence, inadequate data and/ experience) (e.g., usefulness/effectiveness unknown/unclear/uncertain not well established relative to standard of care) D: Not Recommended (Unaccepted) (e.g., considered inappropriate, obsolete, unproven) REFERENCES U.S. Food and Drug Administration (FDA). FDA Guidance Documents. Off-Label and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices. Last updated 03/29/2018. Available at: U.S. Food and Drug Administration (FDA). Developing Orphan Products: FDA and Rare Disease Day. Last updated 01/17/2018. Available at: U.S. Food and Drug Administration (FDA). Orphan Product Designations and Approval Search. Available at: Accessed on June 2018 American Hospital Fmulary Service (AHFS). AHFS Drug Infmation Bethesda, MD: American Society of Health-System Pharmacists. Accesssed via online subscription. Centers f Medicare and Medicaid Services (CMS). Medicare Learning Netwk (MLN) Matters. (June 5, 10, 2008 and July 2008). MLN Matters Number: MM9386. Update to the List of Compendia as Authitative Sources f Use in the Determination of a Medically-Accepted Indication of Drugs and Biologicals Used Off-label in an Anti-Cancer Chemotherapeutic Regimen. Available at: MLN/MLNMattersArticles/downloads/MM9386.pdf Accessed on June 2018 Molina Healthcare Inc. MCP-000: Evaluation of New and Existing Technologies Including Experimental and Investigational Designations (UM 10). Policy Histy MCPC Policy Developed November 2013 Revised Policy June 13, 2014; May 8, 2015 Revised Policy: Reviewed policy. Revision includes: Addition of a recently CMSapproved compendia: Wolters Kluwer Lexi-Drugs (Lexi-Drugs). Clarifications through July 10, 2018 min revisions in wding. Updated references. Page 12 of 12