Sucraid — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does NOT exceed the program quantity limit OR
• If requested dose exceeds quantity limit, meets ONE of the following: (A) no maximum FDA labeled dose exists and there is support for higher dose; OR (B) requested dose within maximum FDA labeled dose and rationale provided why cannot be achieved with different strength; OR (C) exceeds FDA labeled dose and there is support for higher dose

Approval duration

BCBSIL 12 months; others 3 months initial / 12 months renewal