resmetirom — Blue Cross Blue Shield of Montana

metabolic dysfunction associated steatohepatitis (MASH)

Initial criteria

1. Patient has a diagnosis of noncirrhotic NASH or MASH (medical records required)
2. Patient has stage F2 or F3 fibrosis confirmed by BOTH: (A) FIB-4 score consistent with stage F2 or F3 fibrosis adjusted for age AND (B) ONE of: (1) Liver biopsy within past 2 years OR (2) VCTE (e.g., Fibroscan) OR (3) ELF score OR (4) MRE
3. If patient has FDA labeled indication, then ONE of: (A) Age within FDA labeling for requested indication OR (B) Support for using requested agent for patient’s age for the requested indication
4. ONE of: (A) If female, alcohol consumption < 20 grams/day OR (B) If male, alcohol consumption < 30 grams/day
5. Patient is being monitored and/or treated for any comorbid conditions (e.g., cardiovascular disease, diabetes, dyslipidemia, hypertension)
6. BOTH: (A) Patient is currently on a weight management regimen (low-calorie diet, increased physical activity, behavioral modifications) AND (B) Patient will continue weight management in combination with requested agent
7. Patient does NOT have ANY: (A) Decompensated cirrhosis AND (B) Moderate to severe hepatic impairment (Child-Pugh Class B or C) AND (C) Any other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis)
8. Prescriber is a specialist in the area of the patient’s diagnosis (e.g., hepatologist, gastroenterologist) or has consulted with one
9. Patient does NOT have any FDA labeled contraindications to the requested agent

1. Patient previously approved for the requested agent through the plan’s Prior Authorization process
2. ONE of: (A) If female, alcohol consumption < 20 grams/day OR (B) If male, alcohol consumption < 30 grams/day
3. BOTH: (A) Patient currently on weight management regimen (low-calorie diet, increased physical activity, behavioral modifications) AND (B) Will continue weight management regimen with requested agent
4. Patient does NOT have ANY: (A) Decompensated cirrhosis AND (B) Moderate to severe hepatic impairment (Child-Pugh Class B or C) AND (C) Any other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis)
5. Patient has had clinical benefit with the requested agent
6. Prescriber is a specialist in the patient’s diagnosis area or has consulted one
7. Patient does NOT have any FDA labeled contraindications to the requested agent

12 months