Freestyle Libre 2 — Blue Cross Blue Shield of New Mexico

Initial criteria

• Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
• 1. The requested quantity does NOT exceed the program quantity limit OR
• 2. The requested quantity exceeds the program quantity limit AND ONE of the following:
•  A. BOTH of the following:
•   1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
•   2. There is support for therapy with a higher dose for the requested indication OR
•  B. BOTH of the following:
•   1. The requested quantity does NOT exceed the maximum FDA labeled dose for the requested indication AND
•   2. There is support for why the requested quantity cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
•  C. BOTH of the following:
•   1. The requested quantity exceeds the maximum FDA labeled dose for the requested indication AND
•   2. There is support for therapy with a higher dose for the requested indication

Approval duration

12 months