Vanrafia (atrasentan hcl) — Blue Cross Blue Shield of New Mexico

Initial criteria

• The requested quantity (dose) does NOT exceed the program quantity limit OR
• If the requested quantity (dose) exceeds the program quantity limit, ONE of the following:
• A. BOTH of the following: (1) The requested agent does NOT have a maximum FDA labeled dose for the indication AND (2) There is support for therapy with a higher dose for the indication OR
• B. BOTH of the following: (1) The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the indication AND (2) There is support for why the requested quantity 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) The requested quantity (dose) exceeds the maximum FDA labeled dose for the indication AND (2) There is support for therapy with a higher dose for the indication

Approval duration

9–12 months