avacopan — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does NOT exceed the program quantity limit OR requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
• — Requested agent does NOT have a maximum FDA labeled dose AND there is support for therapy with a higher dose for the requested indication OR
• — Requested quantity does NOT exceed the maximum FDA labeled dose AND there is support for why requested quantity cannot be achieved with lower quantity of a higher strength that does NOT exceed the quantity limit OR
• — Requested quantity exceeds the maximum FDA labeled dose AND there is support for therapy with a higher dose for the requested indication

Approval duration

12 months (BCBSIL); 6 months initial / 12 months renewal (others)