Rayos (prednisone delayed-release tablet) — Blue Cross Blue Shield of New Mexico
All indications subject to quantity limit
Initial criteria
- Requested quantity (dose) does NOT exceed the program quantity limit OR
- Requested quantity (dose) exceeds program quantity limit AND ONE of the following:
- A. BOTH of the following:
- 1. 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. 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 (dose) 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. 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
12 months (BCBSIL); 6 months (all other plans)