Ebglyss — Blue Cross Blue Shield of Montana
atopic dermatitis
Initial criteria
- Requested quantity does NOT exceed program quantity limit OR
- Requested quantity exceeds program quantity limit AND ONE of the following:
- Requested agent is Ebglyss for atopic dermatitis AND BOTH: request is for initial loading dose AND patient has received <16 consecutive weeks of treatment AND requested quantity does NOT exceed maximum FDA labeled dose for atopic dermatitis OR BOTH: support for therapy for dose exceeding quantity limit (e.g., inadequate response on 250 mg every 2 weeks during initial 16 weeks) with medical records AND requested dose ≤250 mg every 2 weeks OR
- Requested agent does NOT have a maximum FDA labeled dose for requested indication AND support for higher dose for indication OR
- Requested dose does NOT exceed maximum FDA labeled dose for indication AND support for why the request cannot be achieved with lower quantity of higher strength that does not exceed program quantity limit
Approval duration
BCBSIL: 12 months; other plans: initial 6 months, renewal 12 months