Nemluvio — Blue Cross Blue Shield of Montana

Initial criteria

• The requested quantity (dose) does NOT exceed the program quantity limit OR the criteria for quantities above limit met
• If the requested dose exceeds limit AND patient weighs <90 kg, initial loading dose request not exceeding FDA labeled maximum allowed
• If patient weighs ≥90 kg and requested quantity does NOT exceed 60 mg every 4 weeks
• If requested agent does not have maximum FDA labeled dose and there is support for higher dose
• If requested quantity does not exceed maximum FDA labeled dose and justification provided why alternative strength cannot meet dosing requirements

Approval duration

BCBSIL 12 months; others initial 4 months, renewal 12 months