mifepristone — Blue Cross Blue Shield of New Mexico

Initial criteria

• The requested quantity (dose) does not exceed the program quantity limit OR
• The requested quantity exceeds the program quantity limit AND ONE of the following: (A) The requested agent does not have a maximum FDA labeled dose AND therapy with a higher dose is supported, OR (B) The requested quantity does not exceed the maximum FDA labeled dose AND justification is provided why the dose cannot be achieved with a lower quantity of a higher strength that remains within limit

Approval duration

Initial 6 months; Renewal 12 months