Isturisa (osilodrostat phosphate) — Blue Cross Blue Shield of Montana
Quantity Limit exception
Initial criteria
- Requested quantity does not exceed program quantity limit OR
- Requested quantity exceeds program quantity limit AND ONE of the following: (a) requested agent has no maximum FDA-labeled dose and there is support for higher dose OR (b) requested quantity does not exceed maximum FDA-labeled dose and rationale provided why therapeutic target cannot be achieved with fewer or higher-strength tablets within program limit
Approval duration
Initial: 6 months; Renewal: 12 months