trofinetide oral solution 200 MG/ML — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following:
• 1. Requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. Requested quantity (dose) exceeds the 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

BCBSIL:12 months; Others:3 months initial, 12 months renewal