sacrosidase — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of CSID confirmed by ONE of the following: (A) Genetic testing of the sucrase-isomaltase (SI) gene indicates a pathogenic mutation OR (B) Endoscopic biopsy of the small bowel indicates normal small bowel morphology with decreased or absent sucrase activity, isomaltase activity varying from decreased to normal, and decreased maltase activity
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, geneticist, endocrinologist) or has consulted with one
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved 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., gastroenterologist, geneticist, endocrinologist) or has consulted with one
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSIL 12 months; others 3 months (initial) / 12 months (renewal)