Northera — Blue Cross Blue Shield of New Mexico

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:
• BOTH of the following: The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for the requested indication OR
• BOTH of the following: The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND there is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
• BOTH of the following: The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for the requested indication

Approval duration

BCBSIL:12 months; others initial:1 month; renewal:3 months