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givinostat hcl oral suspension 8.86 MG/ML — Blue Cross Blue Shield of Montana

all indications with a defined quantity limit

Initial criteria

  • Quantity Limit for the Target Agent(s) will be approved when ONE of the following:
  • 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  • 2. The requested quantity (dose) exceeds the program quantity limit AND BOTH of the following:
  • A. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
  • B. There is support for therapy with a higher dose for the requested indication

Approval duration

12 months