Yorvipath (palopegteriparatide) — Blue Cross Blue Shield of New Mexico

Initial criteria

• Diagnosis of hypoparathyroidism AND NOT acute post-surgical hypoparathyroidism AND NOT pseudohypoparathyroidism
• If FDA labeled indication: age is within FDA labeling OR prescriber supports use for patient's age
• Baseline albumin-corrected serum calcium ≥ 7.8 mg/dL using calcium and active vitamin D treatment
• Baseline vitamin D above lower limit of normal
• Tried and had inadequate response to maximally tolerated calcium AND vitamin D supplements (e.g., calcitriol, ergocalciferol, cholecalciferol)
• Will continue calcium and vitamin D supplementation while titrating to appropriate dose
• Will NOT be used in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet)
• Prescriber is a specialist (e.g., endocrinologist, nephrologist) or has consulted with such specialist
• No FDA-labeled contraindications

Reauthorization criteria

• Previously approved for Yorvipath through plan’s PA process
• Albumin-corrected total serum calcium between 8.3–10.6 mg/dL
• Demonstrated clinical benefit with Yorvipath
• NOT using Yorvipath in combination with denosumab, estrogen, raloxifene, or Sensipar (cinacalcet)
• Prescriber is a specialist (e.g., endocrinologist, nephrologist) or has consulted with such specialist
• No FDA-labeled contraindications

Approval duration

6–36 months (plan specific: BCBSOK 36 months; BCBSIL/BCBSMT 12 months; all others 6 months; renewal BCBSOK 36 months, others 12 months)