budesonide oral suspension 2 MG/10ML — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does NOT exceed program quantity limit OR requested quantity exceeds program quantity limit AND ONE of the following: (A) requested agent has no maximum FDA labeled dose AND support exists for higher dose for indication OR (B) requested quantity does not exceed maximum FDA labeled dose AND justification provided why lower quantity of higher strength cannot meet need OR (C) requested quantity exceeds maximum FDA labeled dose AND support exists for higher dose for indication

Approval duration

12 months (BCBSIL) or 3 months (all other plans)