resmetirom — Blue Cross Blue Shield of Montana

Initial criteria

• 1. Requested quantity (dose) does NOT exceed program quantity limit OR
• 2. Requested quantity (dose) exceeds program quantity limit AND ONE of: (A) BOTH: (1) Requested agent does NOT have a maximum FDA labeled dose for requested indication AND (2) Support for therapy with higher dose for requested indication OR (B) BOTH: (1) Requested quantity (dose) does NOT exceed maximum FDA labeled dose for requested indication AND (2) Support why requested quantity cannot be achieved with lower quantity of higher strength not exceeding program limit

Approval duration

12 months