pitolisant hcl — Blue Cross Blue Shield of Montana
dose exceeding quantity limit
Initial criteria
- Requested quantity (dose) does NOT exceed program quantity limit OR
- Requested quantity (dose) exceeds limit AND ONE of the following:
- A. BOTH: (1) Requested agent does NOT have a maximum FDA labeled dose; AND (2) Support for therapy with higher dose OR
- B. BOTH: (1) Requested dose does NOT exceed maximum FDA labeled dose; AND (2) Support for why lower quantity of higher strength not feasible OR
- C. BOTH: (1) Requested dose exceeds maximum FDA labeled dose; AND (2) Support for therapy with higher dose for requested indication
Approval duration
12 months