Empaveli (pegcetacoplan) — Blue Cross Blue Shield of Montana
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Initial criteria
- Requested quantity (dose) does NOT exceed the program quantity limit OR BOTH of the following:
- Requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
- - Patient has lactate dehydrogenase (LDH) level > 2× upper limit of normal OR
- - ALL of the following: patient previously had LDH > 2× upper limit of normal and required a dose increase; patient is currently using the requested quantity; requested quantity does NOT exceed 1,080 mg every three days
Approval duration
12 months