Quantity Limit Exception Criteria Medicare Part D

The requested medication will be approved when BOTH of the following are met: 

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication AND
2. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months