chenodiol — Blue Cross Blue Shield of Montana

Quantity limit criteria

Initial criteria

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
The requested quantity (dose) does NOT exceed the program quantity limit OR
The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
A. BOTH of the following: (1) The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND (2) There is support for therapy with a higher dose for the requested indication OR
B. BOTH of the following: (1) The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND (2) There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
C. BOTH of the following: (1) The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND (2) There is support for therapy with a higher dose for the requested indication

12 months