Skyclarys — Blue Cross Blue Shield of New Mexico

Initial criteria

• Requested quantity (dose) does NOT exceed the program quantity limit OR
• Requested quantity (dose) exceeds the program quantity limit AND ONE of the following applies: (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 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