Sohonos — Blue Cross Blue Shield of Kansas

any other FDA labeled indication of Sohonos with matching route of administration

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 Sohonos within the past 90 days (starting on samples is not approvable) OR
2. The prescriber states the patient has been treated with Sohonos within the past 90 days (starting on samples is not approvable) AND is at risk if therapy is changed
OR
B. BOTH of the following:
1. ONE of the following:
A. The patient has a diagnosis of fibrodysplasia ossificans progressiva (FOP) AND ALL of the following:
1. Genetic analysis confirms mutation in the activin receptor IA (ACVR1) gene AND
2. The patient has signs of heterotopic ossification (HO) AND
3. The requested agent will be used to reduce the volume of new heterotopic ossification
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
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, geneticist, rheumatologist) or has consulted with such a specialist
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., endocrinologist, geneticist, rheumatologist) or has consulted with such a specialist
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 months