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

Initial criteria

• 1. Requested quantity does NOT exceed program quantity limit OR
• 2. Requested quantity exceeds program quantity limit AND ONE of the following: (A) BOTH: (1) Requested agent lacks a maximum FDA labeled dose for requested indication AND (2) Support exists for higher dose therapy OR (B) BOTH: (1) Requested quantity does not exceed maximum FDA labeled dose AND (2) Support exists for why equivalent dosing cannot be achieved with fewer units of a higher strength within limit OR (C) BOTH: (1) Requested quantity exceeds maximum FDA labeled dose AND (2) Support exists for higher dose therapy

Approval duration

BCBSIL:12 months; others:3 months