leniolisib phosphate — Blue Cross Blue Shield of Montana
All indications per quantity limit program
Initial criteria
- Requested quantity (dose) does NOT exceed the program quantity limit OR
- Requested quantity (dose) exceeds limit AND ONE of: (A) Agent has no maximum FDA labeled dose AND there is support for higher dose; OR (B) Requested dose within FDA labeled maximum AND rationale provided why lower quantity of higher strength cannot meet need; OR (C) Requested dose exceeds FDA maximum AND there is support for higher dose therapy
Approval duration
12 months (BCBSIL); 3 months initial and 12 months renewal (all other plans)