Zelsuvmi — Blue Cross Blue Shield of Montana

Initial criteria

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

Approval duration

12 weeks (BCBSMT)