Androgel — Blue Cross Blue Shield of Montana
any indication where higher dose quantity exceeding program limit is requested
Initial criteria
- Quantity limit for Target Agent(s) approved when ONE of the following:
- 1. Requested quantity (dose) does not exceed program quantity limit OR
- 2. Requested quantity (dose) exceeds program limit AND ONE of the following:
- A. BOTH: agent has no maximum FDA labeled dose for indication AND support for therapy with higher dose OR
- B. BOTH: requested quantity does not exceed maximum FDA labeled dose AND support for why requested quantity cannot be achieved with lower quantity of higher strength not exceeding program limit OR
- C. BOTH: requested quantity exceeds maximum FDA labeled dose AND support for therapy with higher dose for indication.
Approval duration
6 months (delayed puberty initial), 12 months (all other indications and renewals)