Sevenfact — Blue Cross Blue Shield of Montana
on-demand treatment with coagulation factor VIIa agents
Initial criteria
- Quantity limit for the requested agent will be approved when ONE of the following are met: (1) requested quantity (dose) does NOT exceed program limit defined by BOTH (A) dose within FDA label AND (B) quantity appropriate based on intended use (on-demand) OR (2) there is support for exceeding the defined program quantity limit (medical records required)
Approval duration
BCBSIL: 12 months; all other plans: up to 3 months