Rayos — Blue Cross Blue Shield of Montana
All indications (Quantity Limit override)
Initial criteria
- Quantity Limit for Rayos will be approved when ONE of the following is met:
- 1. The requested quantity does NOT exceed the program limit OR
- 2. The requested quantity exceeds the limit AND ONE of the following:
- A. Rayos does NOT have a maximum FDA labeled dose for the requested indication AND there is support for higher dose therapy OR
- B. The requested quantity does NOT exceed the maximum FDA labeled dose AND there is justification why a lower quantity of a higher strength cannot meet dosing needs OR
- C. The requested quantity exceeds the maximum FDA labeled dose AND there is support for therapy with a higher dose for the requested indication.
Approval duration
12 months (BCBSIL); 6 months (other plans)