trofinetide oral solution 200 MG/ML — Blue Cross Blue Shield of New Mexico

classic/typical Rett syndrome (RTT)

Initial criteria

1. ALL of the following:
A. Diagnosis of classic/typical Rett syndrome (RTT)
B. Disease-causing mutation in the MECP2 gene [chart notes required]
C. If the patient has an FDA labeled indication, then ONE of the following:
A. The 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
D. Patient's weight is ≥ 9 kg
E. Prescriber has assessed baseline status (prior to therapy with the requested agent) of the patient's RTT symptoms (e.g., speech patterns, hand movements, gait, growth, muscle tone, seizures, breathing patterns, quality of sleep)
2. Prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist, neurologist, pediatrician) or prescriber has consulted with such a specialist
3. Patient does NOT have any FDA labeled contraindications to the requested agent

1. Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
2. Patient has had clinical benefit with the requested agent
3. Prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist, neurologist, pediatrician) or prescriber has consulted with such a specialist
4. Patient does NOT have any FDA labeled contraindications to the requested agent

BCBSIL:12 months; Others:3 months initial, 12 months renewal