Evrysdi — Blue Cross Blue Shield of New Mexico
quantity limit requests above program limit
Initial criteria
- Requested quantity does NOT exceed program quantity limit OR
- ALL of the following: (A) Requested quantity exceeds program quantity limit AND (B) Requested dose does NOT exceed maximum FDA labeled dose AND (C) Support for therapy with higher dose exists OR
- ALL of the following: (A) Requested quantity exceeds program quantity limit AND (B) No maximum FDA labeled dose exists AND (C) Support for why requested quantity cannot be achieved with a lower quantity of higher strength within limit OR
- ALL of the following: (A) Requested quantity exceeds program quantity limit AND (B) Requested dose exceeds maximum FDA labeled dose AND (C) Support for therapy with higher dose exists
Approval duration
12 months