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Ekterly — Blue Cross Blue Shield of Montana

Hereditary angioedema

Initial criteria

  • Quantity Limit for the target agent(s) will be approved when ONE of the following is met:
  • 1. The requested quantity (dose) is within the program quantity limit (allows for 2 acute HAE attacks per month) OR
  • 2. The requested quantity (dose) exceeds the program quantity limit and there is support for therapy with a higher dose or quantity for the requested indication (e.g., frequency of attacks within the past 3 months has been greater than 2 attacks per month)

Approval duration

initial 6 months; renewal 12 months (BCBSIL: 12 months)