Filspari — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. Requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. Requested quantity (dose) exceeds the program quantity limit AND ONE of: (A) Requested agent has no maximum FDA labeled dose for indication AND therapy with higher dose supported OR (B) Requested quantity does NOT exceed maximum FDA labeled dose AND support provided why dose cannot be achieved with lower quantity of higher strength that is within limit OR (C) Requested dose exceeds maximum FDA labeled dose AND therapy with higher dose supported

Approval duration

12 months