risdiplam — Blue Cross Blue Shield of Montana

all labeled indications

Initial criteria

Requested quantity (dose) does NOT exceed the program quantity limit OR one of the following sets of criteria:
A. Requested quantity (dose) exceeds program quantity limit AND B. Requested quantity (dose) does NOT exceed maximum FDA labeled dose AND C. There is support for therapy with a higher dose for the requested indication
A. Requested quantity (dose) exceeds program quantity limit AND B. Requested quantity (dose) does NOT have a maximum FDA labeled dose AND C. There is support for why requested dose cannot be achieved with lower quantity of higher strength that does NOT exceed program limit
A. Requested quantity (dose) exceeds program quantity limit AND B. Requested quantity (dose) exceeds maximum FDA labeled dose AND C. There is support for therapy with a higher dose for the requested indication

12 months