Crenessity — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND ONE of the following: (1) The patient has been treated with the requested agent (not including samples) within the past 90 days OR (2) The prescriber states the patient has been treated with the requested agent (not including samples) within the past 90 days AND is at risk if therapy is changed OR (B) BOTH of the following: (1) The patient has a diagnosis of classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency confirmed by ONE of the following: (A) Positive infant screening with secondary tier 2 confirmatory testing OR (B) Elevated serum 17-hydroxyprogesterone level (17OHP) above ULN OR (C) Cosyntropin (ACTH) stimulation test OR (D) Genetic testing for mutation in the СΥΡ21Α2 gene consistent with CAH 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 OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The patient is currently treated with glucocorticoid replacement therapy (hydrocortisone, prednisone, prednisolone, or dexamethasone)
• The patient will continue glucocorticoid replacement therapy in combination with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist), or has consulted with such a specialist
• 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 had clinical benefit with the requested agent
• The patient is currently treated with glucocorticoid replacement therapy
• The patient will continue glucocorticoid replacement therapy in combination with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist), or has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months