Wegovy — Blue Cross Blue Shield of Montana
quantity limit exception for maintenance therapy dosing
Initial criteria
- Requested quantity does NOT exceed program quantity limit OR
- Requested quantity exceeds program quantity limit AND patient meets one of the following:
- A. For Wegovy 0.5 mg or 1 mg for maintenance: patient cannot use FDA-labeled maintenance strength AND has had clinical benefit on requested lower strength
- B. Requested agent does not have a maximum FDA labeled dose for the indication AND there is support for higher dosing
- C. Requested quantity does not exceed maximum FDA labeled dose AND there is justification why requested dose cannot be achieved with fewer units of higher strength
- D. Requested quantity exceeds maximum FDA labeled dose AND there is support for therapy with higher dose
Approval duration
12 months