Freestyle Libre — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity limit for the target agent(s) will be approved when ONE of the following is met:
• 1. Requested quantity does NOT exceed the program quantity limit OR
• 2. Requested quantity exceeds the program quantity limit AND ONE of the following:
• A. BOTH of the following:
• 1. Requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
• 2. Support exists for therapy with a higher dose for the requested indication OR
• B. BOTH of the following:
• 1. Requested quantity does NOT exceed the maximum FDA labeled dose for the requested indication AND
• 2. Support is provided for why requested quantity cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
• C. BOTH of the following:
• 1. Requested quantity exceeds the maximum FDA labeled dose for the requested indication AND
• 2. Support exists for therapy with a higher dose for the requested indication.

Reauthorization criteria

• Same as initial criteria when quantity limit conditions continue to be met.

Approval duration

12 months