cenegermin-bkbj — Blue Cross Blue Shield of New Mexico
neurotrophic keratitis (NK) with quantity limit
Initial criteria
- Quantity Limit for the target agent(s) will be approved when ONE of the following is met: 1. The requested quantity (dose) does NOT exceed the program quantity limit OR 2. The requested quantity (dose) exceeds the program limit AND BOTH of the following: A. The patient has bilateral neurotrophic keratitis (NK) AND B. The requested quantity does NOT exceed TWICE the program quantity limit
Approval duration
16 weeks (all other plans); 12 months (BCBSIL)