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Radicava ors — Blue Cross Blue Shield of New Mexico

quantity limit exception criteria

Initial criteria

  • ONE of the following: (1) The requested quantity (dose) 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
  • B. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication
  • 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

Approval duration

BCBSIL:12months; others:6months initial,12months renewal