sacrosidase — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. The patient has a diagnosis of congenital sucrase-isomaltase deficiency (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 in the presence of decreased (or absent) sucrase activity, isomaltase activity varying from decreased to normal activity, and decreased maltase activity AND
• 2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, geneticist, endocrinologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent
• Length of Approval: BCBSIL: 12 months ALL other plans: 3 months

Reauthorization criteria

• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review] AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, geneticist, endocrinologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent
• Length of Approval: 12 months

Approval duration

initial: 3–12 months; renewal: 12 months