olezarsen sodium subcutaneous solution auto-injector — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity (dose) does not exceed the program quantity limit OR exceeds the limit AND ONE of the following: (A) Agent has no maximum FDA labeled dose and there is support for higher dose OR (B) Requested dose does not exceed maximum labeled dose and justification provided why lower quantity of higher strength not possible OR (C) Requested dose exceeds maximum labeled dose and there is support for higher dose therapy

Approval duration

6–12 months (BCBSIL = 12 months; others = 6 months initial, 12 months renewal)