Radicava ors starter kit — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity limit will be approved when ONE of the following is met:
• 1. Requested quantity (dose) does NOT exceed program quantity limit OR
• 2. Requested quantity (dose) exceeds program quantity limit AND ONE of the following:
• A. BOTH of the following:
• 1. Requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
• 2. Support for therapy with higher dose for requested indication OR
• B. Requested quantity (dose) does NOT exceed maximum FDA labeled dose for requested indication OR
• C. BOTH of the following:
• 1. Requested quantity (dose) exceeds maximum FDA labeled dose for requested indication AND
• 2. Support for therapy with higher dose for requested indication

Approval duration

BCBSIL: 12 months; All other plans: Initial 6 months, Renewal 12 months