Andembry — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) is within FDA labeled dose AND program quantity limit
• OR requested quantity exceeds program limit AND there is support for higher dose or quantity for the requested indication

Approval duration

BCBSIL: 12 months; other plans: Initial – Cinryze 3 months, Haegarda 4 months, Andembry or Orladeyo 6 months, Takhzyro 9 months; Renewal – 12 months