sacrosidase — Blue Cross Blue Shield of Alabama

Initial criteria

• Diagnosis of congenital sucrase-isomaltase deficiency (CSID) confirmed by ONE of the following:
• - Genetic testing of the sucrase-isomaltase (SI) gene indicates a pathogenic mutation OR
• - Endoscopic biopsy of the small bowel indicates normal small bowel morphology in the presence of decreased (or absent) sucrase activity, isomaltase activity varying from decreased to normal activity, and decreased maltase activity
• AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, geneticist, endocrinologist) or has consulted with a specialist in the area of the patient’s diagnosis
• AND the patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s prior authorization process
• AND the patient has had clinical benefit with the requested agent
• AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, geneticist, endocrinologist) or has consulted with a specialist in the area of the patient’s diagnosis
• AND the patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 3 months; renewal 12 months