ozanimod — Blue Cross Blue Shield of New Mexico
quantity limit exception
Initial criteria
- Requested dose does NOT exceed program quantity limit OR
- ALL of the following: (a) requested dose exceeds program quantity limit AND (b) requested dose does NOT exceed maximum FDA labeled dose for requested indication AND (c) requested quantity cannot be achieved with lower quantity of higher strength within limit OR
- ALL of the following: (a) requested dose exceeds program quantity limit AND (b) requested dose exceeds maximum FDA labeled dose for requested indication AND (c) prescriber provided supporting information for therapy at higher dose
Approval duration
12 months