Ebglyss — Blue Cross Blue Shield of New Mexico

Initial criteria

• Quantity limit approval if requested quantity does NOT exceed program limit OR
• If quantity exceeds limit, approval when: (A) Ebglyss for atopic dermatitis AND EITHER (1) initial loading dose, patient <16 consecutive weeks of treatment, quantity ≤ FDA labeled dose OR (2) supported therapy at higher dose not exceeding 250 mg every 2 weeks OR
• (B) Agent has no maximum FDA labeled dose AND supported therapy for higher dose OR
• (C) Quantity ≤ max FDA labeled dose AND rationale supplied why cannot use lower quantity of higher strength that is within program limit

Approval duration

BCBSIL: 12 months; others: initial 6 months, renewal 12 months