atrasentan hcl — Blue Cross Blue Shield of Montana
quantity limit exception
Initial criteria
- ONE of the following: (1) Requested quantity (dose) does NOT exceed program quantity limit OR
- Requested quantity (dose) exceeds program quantity limit AND ONE of the following:
- A. BOTH of the following: (1) Requested agent does NOT have a maximum FDA labeled dose for requested indication AND (2) There is support for therapy with higher dose for requested indication OR
- B. BOTH of the following: (1) Requested quantity (dose) does NOT exceed maximum FDA labeled dose for requested indication AND (2) There is support why requested quantity cannot be achieved with lower quantity of higher strength that does NOT exceed program quantity limit OR
- C. BOTH of the following: (1) Requested quantity (dose) exceeds maximum FDA labeled dose for requested indication AND (2) There is support for therapy with higher dose for requested indication
Approval duration
12 months (BCBSIL initial and renewals); 9 months (others initial)