Lupkynis — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does NOT exceed program quantity limit OR
• Requested quantity (dose) exceeds program quantity limit AND EITHER (A) requested agent does NOT have a maximum FDA labeled dose AND there is support for higher dose for the requested indication OR (B) requested quantity does NOT exceed the maximum FDA labeled dose AND there is support for why requested quantity cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit

Approval duration

12 months