budesonide delayed release capsule 4 mg — Blue Cross Blue Shield of Montana
quantity limit exception for labeled indications
Initial criteria
- Requested quantity (dose) does not exceed program quantity limit OR
- Requested quantity exceeds program quantity limit AND ONE of the following:
- A. Agent does not have a maximum FDA labeled dose for indication AND there is support for higher dose use
- B. Requested quantity ≤ maximum FDA labeled dose AND support exists for why dose cannot be achieved with lower quantity of higher strength within limit
- C. Requested quantity exceeds maximum FDA labeled dose AND support exists for therapy with higher dose
Approval duration
BCBSIL: 12 months; Others: 10 months