vosoritide — Blue Cross Blue Shield of Montana

Initial criteria

• ONE of the following: (A) ALL of the following: (1) Patient has a diagnosis of achondroplasia confirmed by genetic testing OR radiographic findings (medical records required); AND (2) Requested agent will be used to increase linear growth; AND (3) Imaging indicates patient does not have closed epiphyses if female age > 12 years or male age > 14 years (medical records required) OR (B) Patient has another FDA labeled indication for requested agent and route of administration
• If patient has an FDA labeled indication, then ONE of the following: (A) 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
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or prescriber has consulted with a specialist in the area of the patient’s diagnosis
• Patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Imaging indicates the patient does not have closed epiphyses if female age > 12 years or male age > 14 years (medical records required)
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or prescriber has consulted with a specialist in the area of the patient’s diagnosis
• Patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months