Qbrexza — Blue Cross Blue Shield of Montana
quantity limit exceedance requests
Initial criteria
- Requested quantity (dose) does NOT exceed the program quantity limit OR requested quantity exceeds the program quantity limit AND ONE of the following:
- A. BOTH: (1) requested agent does NOT have a maximum FDA labeled dose for the requested indication AND (2) support for therapy with a higher dose
- B. BOTH: (1) requested quantity does NOT exceed the maximum FDA labeled dose AND (2) support for why dose cannot be achieved with a lower quantity of a higher strength within limit
- C. BOTH: (1) requested quantity exceeds the maximum FDA labeled dose AND (2) support for therapy with a higher dose for the requested indication
Approval duration
12 months (BCBSIL); others initial 3 months, renewal 12 months