icosapent ethyl — Blue Cross Blue Shield of Montana
quantity limit exceptions
Initial criteria
- Requested quantity (dose) does not exceed program quantity limit OR requested quantity exceeds program quantity limit AND ONE of the following:
- (A) BOTH: (1) Requested agent does not have a maximum FDA labeled dose for the requested indication AND (2) There is support for therapy with a higher dose for the requested indication
- OR (B) BOTH: (1) Requested quantity does not exceed maximum FDA labeled dose AND (2) Support for why lower quantity of higher strength not suitable
- OR (C) BOTH: (1) Requested quantity exceeds maximum FDA labeled dose AND (2) Support for therapy with higher dose for requested indication
Approval duration
12 months