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