diazoxide choline — Blue Cross Blue Shield of Kansas

Initial criteria

• 1. ONE of the following:
• A. The patient has a diagnosis of Prader-Willi syndrome AND BOTH of the following:
• 1. The patient has hyperphagia AND
• 2. The patient's diagnosis has been confirmed by genetic testing indicating mutation on chromosome 15 (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, geneticist), or has consulted with a specialist in the area of the patient’s diagnosis AND
• 4. 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. The patient has had clinical benefit with the requested agent AND
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist), or has consulted with a specialist in the area of the patient’s diagnosis AND
• 4. The patient does NOT have any FDA-labeled contraindications to the requested agent

Approval duration

initial 4 months; renewal 12 months