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

Initial criteria

• 1. Member resides in Ohio AND
• 2. Plan is Fully Insured or HIM Shop (SG) AND
• 3. Patient does NOT have any FDA labeled contraindications to the requested agent AND
• 4. ONE of the following: (A) Patient has another FDA labeled indication for requested agent & route OR (B) Patient has another indication supported in compendia for requested agent & route OR (C) Prescriber submitted two peer-reviewed professional journal articles supporting proposed use as safe and effective (acceptable study designs include randomized, double-blind, placebo-controlled clinical trials; case studies not accepted)

Approval duration

12 months