Mavenclad (cladribine) — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND there is support why the requested quantity cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit OR BOTH of the following: (a) requested quantity exceeds the maximum FDA labeled dose for the requested indication AND (b) there is support for therapy with a higher dose for the requested indication
• Requested quantity (dose) does NOT exceed the program quantity limit OR BOTH of the following: (a) requested quantity exceeds the program quantity limit AND (b) the requested quantity cannot be achieved with a lower quantity of packs and a higher pack size that does not exceed the program quantity limit (examples: two 10 tablet packs instead of four 5 tablet packs)

Approval duration

Initial: 36 weeks for new starts or remainder of annual course; Renewal: 3 months