NovoSeven RT — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity limit for the requested agent will be approved when ONE of the following is met: (1) requested quantity (dose) does NOT exceed program quantity limit defined by BOTH (A) requested dose within FDA labeled dosing AND (B) quantity appropriate based on intended use (on-demand, prophylaxis, perioperative) OR (2) there is documentation supporting need to exceed the defined program quantity limit (medical records required)

Approval duration

BCBSIL: 12 months; all other plans: peri-operative 1 request, on-demand up to 3 months, prophylaxis up to 12 months, ITT/ITI up to 6 months or total 33 months, all other up to 3 months