omaveloxolone — Blue Cross Blue Shield of Montana

Friedreich ataxia (FA, FRDA) with mutation in the frataxin (FXN) gene

Initial criteria

Diagnosis of Friedreich ataxia with genetic analysis confirming mutation in the FXN gene [chart notes required]
If the patient has an FDA labeled indication, then ONE of the following: (1) patient's age is within FDA labeling for the requested indication OR (2) there is support for use at the patient's age for the requested indication
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist, neurologist) OR has consulted with such a specialist
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 had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist, neurologist) OR has consulted with such a specialist
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months