Yorvipath — Blue Cross Blue Shield of Montana

Initial criteria

• The requested quantity (dose) does NOT exceed the program quantity limit OR
• If the requested quantity (dose) exceeds the program quantity limit, ONE of the following: (A) The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND there is support for therapy with a higher dose for that indication OR (B) The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND there is support for why the dose cannot be achieved with fewer higher-strength units OR (C) The requested quantity (dose) exceeds the maximum FDA labeled dose for the indication AND there is support for therapy with a higher dose

Approval duration

12 months