Movantik (naloxegol) — Blue Cross Blue Shield of New Mexico

constipation (quantity limit override)

Initial criteria

The requested quantity (dose) does NOT exceed the program quantity limit; OR
The requested quantity (dose) 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 (dose) 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 (dose) 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.

12 months