ozanimod — 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 does NOT exceed the maximum FDA labeled dose AND cannot be achieved with a lower quantity of a higher strength within limit; OR
- Requested quantity (dose) exceeds both program and FDA limits AND prescriber provides supporting clinical justification for higher dosing
Approval duration
12 months