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The Policy VaultThe Policy Vault

vosoritide — Blue Cross Blue Shield of New Mexico

Achondroplasia

Initial criteria

  • 1. ONE of the following: A. ALL of the following: 1. The patient has a diagnosis of achondroplasia as confirmed by ONE of the following (medical records required): A. Genetic testing OR B. Radiographic findings AND 2. The requested agent will be used to increase linear growth AND 3. Imaging indicates the patient does not have closed epiphyses if the member is female and over the age of 12 or if the member is male and over the age of 14 [medical records are required] OR B. The patient has another FDA labeled indication for the requested agent and route of administration
  • 2. 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
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the patient’s diagnosis
  • 4. The patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent
  • Alternate approval: The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: A. The patient does NOT have any FDA labeled contraindications to the requested agent AND B. ONE of the following: 1. The patient has another FDA labeled indication for the requested agent and route of administration OR 2. The patient has another indication supported in compendia for the requested agent and route of administration OR 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective

Reauthorization criteria

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

Approval duration

12 months