Voxzogo (vosoritide) — Blue Cross Blue Shield of Kansas

Any other FDA labeled indication for the requested agent and route of administration

Initial criteria

Diagnosis of achondroplasia confirmed by genetic testing OR radiographic findings
Requested agent will be used to increase linear growth
Patient has open epiphyses OR has another FDA labeled indication for the requested agent
Patient’s age is within FDA labeling for the requested indication OR there is support for using the agent for the patient’s age for that indication
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) OR has consulted with such a specialist
Patient will NOT use the agent in combination with another growth hormone agent for the requested indication
Patient does NOT have any FDA labeled contraindications to the requested agent

Patient was previously approved for the requested agent through the plan’s prior authorization process
Patient has open epiphyses
Patient has had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) OR has consulted with such a specialist
Patient will NOT use the agent in combination with another growth hormone agent for the requested indication
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months