Voxzogo (vosoritide) — Blue Cross Blue Shield of Alabama

Initial criteria

• - The patient has a diagnosis of achondroplasia as confirmed by ONE of the following (medical records required): • Genetic testing OR • Radiographic findings
• - The requested agent will be used to increase linear growth
• - The patient has open epiphyses OR the patient has another FDA labeled indication for the requested agent and route of administration
• - If the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested indication for the requested agent OR • There is support for using the requested agent for the patient’s age for the requested indication
• - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• - The patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
• - The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• - The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• - The patient has open epiphyses
• - The patient has had clinical benefit with the requested agent
• - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• - The patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
• - The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months