Rebif — Blue Cross Blue Shield of New Mexico
Multiple sclerosis disease modification
Initial criteria
- Requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
- There is support 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: 1. The requested quantity exceeds the maximum FDA labeled dose AND 2. There is support for therapy with a higher dose for the requested indication
Approval duration
12 months