Restasis — Blue Cross Blue Shield of Montana

Initial criteria

• The requested quantity (dose) does NOT exceed the program quantity limit OR
• The requested quantity (dose) exceeds the program quantity limit AND ONE of the following: BOTH of the following: The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for the requested indication OR The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication OR BOTH of the following: The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for the requested indication

Approval duration

12 months