Zokinvy — Blue Cross Blue Shield of Kansas

Initial criteria

• Genetic testing has confirmed heterozygous LMNA mutation with progerin-like protein accumulation (medical record required) OR genetic testing has confirmed homozygous or compound heterozygous ZMPSTE24 mutations (medical record required)
• 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
• The patient has a body surface area (BSA) ≥ 0.39 m^2
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist) or the prescriber 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 had clinical benefit with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist) or the prescriber 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

12 months