Xphozah — Blue Cross Blue Shield of Montana
quantity limit exceeding requests
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)