Skip to content
The Policy VaultThe Policy Vault

Voxzogo — Blue Cross Blue Shield of Illinois

achondroplasia

Initial criteria

  • 1. ONE of the following:
  • A. ALL of the following:
  • 1. The patient has a diagnosis of achondroplasia as confirmed by ONE of the following (medical records required):
  • A. Genetic testing OR
  • B. Radiographic findings AND
  • 2. The requested agent will be used to increase linear growth AND
  • 3. Imaging indicates the patient does not have closed epiphyses if the member is female and over the age of 12 or if the member is male and over the age of 14 [medical records required] OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration AND
  • 2. If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication AND
  • 3. 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 AND
  • 4. The patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication AND
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • 2. Imaging indicates the patient does not have closed epiphyses if the member is female and over the age of 12 or if the member is male and over the age of 14 [medical records required] AND
  • 3. The patient has had clinical benefit with the requested agent AND
  • 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with one AND
  • 5. The patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication AND
  • 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months