omaveloxolone — Blue Cross Blue Shield of New Mexico

Initial criteria

• Diagnosis of Friedreich ataxia (FA, FRDA) confirmed by genetic analysis of frataxin (FXN) gene [chart notes required]
• If 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 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., cardiologist, geneticist, neurologist), OR prescriber has consulted with a specialist in the area of the patient’s diagnosis
• 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
• 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 prescriber has consulted with a specialist in the area of the patient’s diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months