lonafarnib — Blue Cross Blue Shield of Kansas

Initial criteria

• 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
• OR ALL 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:
• – heterozygous LMNA mutation with progerin-like protein accumulation OR homozygous or compound heterozygous ZMPSTE24 mutations