Xdemvy — Blue Cross Blue Shield of Montana

Initial criteria

• For Quantity Limit override: ONE of the following:
• 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following: BOTH a) The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND b) There is support for therapy with a higher dose for the requested indication OR The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication.

Approval duration

2 months (all other plans); 12 months (BCBSIL)