mifepristone — Blue Cross Blue Shield of Montana
All indications with quantity limit override request
Initial criteria
- Requested quantity (dose) does not exceed program quantity limit OR
- Requested quantity exceeds program limit AND EITHER: (A) there is no maximum FDA labeled dose and support for higher dose exists, OR (B) dose does not exceed FDA max and there is justification why requested quantity cannot be achieved with lower quantity of higher strength formulation
Approval duration
Initial 6 months; Renewal 12 months