satralizumab-mwge — Blue Cross Blue Shield of Montana

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:
• BOTH of the following: requested agent does NOT have a maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for the requested indication OR BOTH of the following: requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND there is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit

Approval duration

12 months