Otezla (apremilast) — Blue Cross Blue Shield of Montana

Quantity limit exception

Initial criteria

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: (1) The requested agent does NOT have a maximum FDA labeled dose for the indication AND (2) There is support for therapy with a higher dose for the indication (submitted trials or guidelines required)
OR
B. BOTH of the following: (1) The requested quantity does NOT exceed the maximum FDA labeled dose for the indication AND (2) The requested quantity cannot be achieved with a lower quantity of a higher strength that does not exceed the program limit
OR
C. BOTH of the following: (1) The requested quantity exceeds the maximum FDA labeled dose for the requested indication AND (2) There is support for therapy with a higher dose (submitted trials or guidelines required)

12 months