danicopan — Blue Cross Blue Shield of Montana

all approved indications for target agent where higher than standard quantity requested

Initial criteria

Requested quantity (dose) does NOT exceed the program quantity limit OR
If the requested quantity exceeds the program limit, then ONE of the following: (A) BOTH of: (1) The agent does NOT have a maximum FDA labeled dose for the indication AND (2) There is support for therapy with a higher dose for the indication OR (B) BOTH of: (1) Requested dose does NOT exceed maximum FDA labeled dose AND (2) Support for why the dose cannot be achieved with a lower quantity of a higher strength within the quantity limit OR (C) BOTH of: (1) Requested dose exceeds maximum FDA labeled dose AND (2) There is support for therapy with a higher dose for the indication

BCBSIL: 12 months; others initial: 3 months, renewal: 12 months