Zokinvy — Blue Cross Blue Shield of Alabama

Initial criteria

• - ONE of the following:
• • The requested agent is eligible for continuation of therapy AND ONE of the following:
• ◦ The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
• ◦ The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
• • ALL of the following:
• ◦ ONE of the following:
• ▪ The patient has a diagnosis of Hutchinson-Gilford progeria syndrome (HGPS) AND genetic testing has confirmed a pathogenic variant in the LMNA gene that results in production of progerin (medical record required) OR
• ▪ The patient has a processing-deficient progeroid laminopathy AND ONE of the following:
• – Genetic testing has confirmed heterozygous LMNA mutation with progerin-like protein accumulation (medical record required) OR
• – Genetic testing has confirmed homozygous or compound heterozygous ZMPSTE24 mutations (medical record required)
• ◦ 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