Veozah — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity limit for the target agent will be approved when ONE of the following is met:
• 1. Requested quantity does NOT exceed the program quantity limit OR
• 2. Requested quantity exceeds program quantity limit AND ONE of the following:
•   A. BOTH:
•     1. The agent does NOT have a maximum FDA-labeled dose for the indication AND
•     2. There is support for therapy with a higher dose for the indication OR
•   B. BOTH:
•     1. Requested quantity does NOT exceed maximum FDA-labeled dose AND
•     2. There is support for why requested dose cannot be achieved with lower quantity of higher strength not exceeding the program limit OR
•   C. BOTH:
•     1. Requested quantity exceeds maximum FDA-labeled dose AND
•     2. There is support for therapy with a higher dose for the indication

Approval duration

BCBSIL 12 months; others initial 3 months, renewal 12 months