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Ophthalmic Immunomodulators - Cequa Prior Authorization (with Quantity Limit) Criteria - Medicare Part D

Utilization Management Policy

Last Review: 06/26/2023
Prior Authorization and Quantity Limit Criteria for Approval

Cequa will be approved when BOTH of the following are met:

 

    1. ONE of the following:

A. The patient has an FDA labeled indication for the requested medication

 

OR

B. The patient has an indication that is supported in CMS approved compendia for the requested medication

 

 AND

 

    2. ONE of the following:

A. The requested quantity (dose) does NOT exceed the program quantity limit

 

OR

 

B. BOTH of the following:

                i. The requested quantity (dose) is greater than the program quantity limit

 

 AND

 

                ii. The prescriber has provided information in support of therapy with a higher dose for the requested indication

 

Length of Approval: 12 months

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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