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