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The Policy VaultThe Policy Vault

Yorvipath — Blue Cross Blue Shield of Illinois

hypoparathyroidism

Initial criteria

  • Patient has a diagnosis of hypoparathyroidism
  • Patient does NOT have acute post-surgical hypoparathyroidism
  • Patient does NOT have pseudohypoparathyroidism
  • 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 OR there is support for the patient’s age for the requested indication
  • Patient has baseline albumin-corrected serum calcium ≥ 7.8 mg/dL using calcium and active vitamin D treatment
  • Patient has baseline vitamin D levels above the lower limit of normal
  • Patient has tried and had an inadequate response to maximally tolerated calcium AND vitamin D supplements (e.g., calcitriol, ergocalciferol, cholecalciferol)
  • Patient will continue calcium and vitamin D supplementation while titrating to an appropriate dose of the requested agent
  • Patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet)
  • Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist) OR has consulted with a specialist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Alternatively, for members residing in Ohio with Fully Insured or HIM Shop (SG) plans: patient does NOT have any FDA labeled contraindications AND ONE of the following: (A) patient has another FDA labeled indication; OR (B) patient has another compendia-supported indication; OR (C) prescriber has submitted two articles from major peer-reviewed journals supporting the use

Reauthorization criteria

  • Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • Albumin-corrected total serum calcium concentration between 8.3 to 10.6 mg/dL
  • Patient has had clinical benefit with the requested agent
  • Patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet)
  • Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist) OR has consulted with a specialist
  • Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSOK: 36 months; BCBSIL and BCBSMT: 12 months; All other plans: 6 months; Reauth BCBSOK: 36 months; Reauth others: 12 months