palopegteriparatide — Blue Cross Blue Shield of Montana

Initial criteria

• The patient has a diagnosis of hypoparathyroidism AND
• The patient does NOT have acute post-surgical hypoparathyroidism AND
• The patient does NOT have pseudohypoparathyroidism AND
• 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 AND
• The patient has baseline albumin-corrected serum calcium ≥ 7.8 mg/dL using calcium and active vitamin D treatment AND
• The patient has baseline vitamin D levels above the lower limit of normal AND
• The patient has tried and had an inadequate response to maximally tolerated calcium AND vitamin D supplements (e.g., calcitriol, ergocalciferol, cholecalciferol) AND
• The patient will continue calcium and vitamin D supplementation while titrating to an appropriate dose AND
• The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet) AND
• The prescriber is a specialist in endocrinology or nephrology, or has consulted with such a specialist AND
• 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 AND
• The patient has an albumin-corrected total serum calcium concentration between 8.3 and 10.6 mg/dL AND
• The patient has had clinical benefit with the requested agent AND
• The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet) AND
• The prescriber is a specialist in endocrinology or nephrology, or has consulted with such a specialist AND
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSMT); 36 months (BCBSOK); 6 months (others)