berdazimer sodium gel 10.3 % — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following: A. BOTH of the following: 1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND 2. There is support for therapy with a higher dose for the requested indication OR B. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND C. BOTH of the following: 1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND 2. There is support for therapy with a higher dose for the requested indication

Approval duration

BCBSIL: 12 months; ALL other plans: 12 weeks