Empaveli (pegcetacoplan) — Blue Cross Blue Shield of New Mexico
other FDA labeled indications
Initial criteria
- 1. Requested quantity (dose) does NOT exceed program quantity limit OR 2. BOTH: A. Requested quantity (dose) exceeds program quantity limit AND B. ONE of: (1) Patient has lactate dehydrogenase (LDH) > 2× upper limit of normal (lab test required) OR (2) ALL: (A) Patient had prior LDH >2× ULN and required a dose increase AND (B) Patient is currently using requested quantity (dose) AND (C) Requested quantity (dose) does NOT exceed 1,080 mg every three days
Approval duration
12 months