Miplyffa — Blue Cross Blue Shield of Montana
Quantity limit exception
Initial criteria
- The requested quantity (dose) does NOT exceed the program quantity limit OR
- The requested quantity (dose) exceeds the program quantity limit AND one of the following:
- A. (1) The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND (2) There is support for therapy with a higher dose for the requested indication OR
- B. (1) The requested dose does NOT exceed the maximum FDA labeled dose for the indication AND (2) There is support for why the dose cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program limit OR
- C. (1) The requested dose exceeds the maximum FDA labeled dose for the indication AND (2) There is support for therapy with a higher dose for the requested indication
Approval duration
12 months