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Cequa — Blue Cross Blue Shield of New Mexico

dry eye disease

Initial criteria

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

Approval duration

12 months