Skyclarys — Blue Cross Blue Shield of Kansas

Friedreich ataxia (FA, FRDA)

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 (starting on samples is not approvable) within the past 90 days OR
2. 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
B. BOTH of the following:
1. The patient has a diagnosis of Friedreich ataxia (FA, FRDA) with genetic analysis confirming mutation in the frataxin (FXN) gene 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
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist, neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
The patient has had clinical benefit with the requested agent AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist, neurologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months