Filspari — Blue Cross Blue Shield of Montana
Quantity limit exception requests for any indication
Initial criteria
- Requested quantity (dose) does NOT exceed program quantity limit OR
- Requested quantity exceeds program limit AND ONE of: (A) Requested agent has no maximum FDA labeled dose for requested indication AND support for higher dose exists OR (B) Requested quantity does not exceed maximum FDA labeled dose AND support why dose cannot be achieved with lower quantity of higher strength that meets program limit OR (C) Requested quantity exceeds maximum FDA labeled dose AND support for higher dose exists
Approval duration
12 months