Yorvipath — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following:
• A. 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
• B. ALL of the following:
• 1. The patient has a diagnosis of hypoparathyroidism
• 2. The patient does NOT have acute post-surgical hypoparathyroidism
• 3. The patient does NOT have pseudohypoparathyroidism
• 4. If the patient has an FDA labeled indication, then ONE of the following: the patient’s age is within FDA labeling for the requested indication OR there is support for using the requested agent for the patient’s age for the requested indication
• 5. The patient has a baseline albumin-corrected serum calcium of at least 7.8 mg/dL using calcium and active vitamin D treatment
• 6. The patient has baseline vitamin D levels above the lower limit of normal
• 7. The patient has tried and had an inadequate response to maximally tolerated calcium AND vitamin D supplements (e.g., calcitriol, ergocalciferol, cholecalciferol)
• The patient will continue calcium and vitamin D supplementation while titrating to an appropriate dose of the requested agent
• The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, and Sensipar (cinacalcet)
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist), or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has an albumin-corrected total serum calcium concentration between 8.3 to 10.6 mg/dL
• The patient has had clinical benefit with the requested agent
• The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, and Sensipar (cinacalcet)
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist), or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 6 months; renewal 12 months