tenapanor hcl — Blue Cross Blue Shield of Montana

Initial criteria

• Requested quantity does NOT exceed program quantity limit; OR if exceeds, BOTH of the following:
• — Patient is NOT receiving dialysis; AND ONE of the following:
• 1. Requested agent has no maximum FDA labeled dose and there is support for higher dose OR
• 2. Requested quantity does not exceed maximum FDA labeled dose and justification provided why lower quantity of higher strength not feasible OR
• 3. Requested quantity exceeds maximum FDA labeled dose and there is support for therapy with higher dose.

Approval duration

12 months (BCBSIL); 3 months (others)