Vivjoa — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following: 1) The requested quantity (dose) does NOT exceed the program quantity limit; OR 2) The requested quantity exceeds the program quantity limit AND ONE of the following: A) BOTH of the following: i) The requested agent does NOT have a maximum FDA labeled dose for the requested indication; AND ii) There is support for therapy with a higher dose for the requested indication; OR B) BOTH of the following: i) The requested quantity does NOT exceed the maximum FDA labeled dose for the requested indication; AND ii) There is support for why the requested quantity cannot be achieved with a lower quantity of a higher strength; OR C) BOTH of the following: i) The requested quantity exceeds the maximum FDA labeled dose for the requested indication; AND ii) There is support for therapy with a higher dose for the requested indication

Approval duration

BCBSIL 12 months; all other plans: 3 months for treatment of vulvovaginal candidiasis, 6 months for recurrent vulvovaginal candidiasis or other indications; Vivjoa 4 months