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Zokinvy — Blue Cross Blue Shield of New Mexico

Other FDA labeled indication

Initial criteria

  • ONE of the following: (A) BOTH of the following: (1) Diagnosis of Hutchinson-Gilford progeria syndrome (HGPS) AND (2) Genetic testing has confirmed a pathogenic variant in the LMNA gene that results in production of progerin (medical record required) OR (B) The patient has a processing-deficient progeroid laminopathy AND ONE of the following: (1) Genetic testing has confirmed heterozygous LMNA mutation with progerin-like protein accumulation (medical record required) OR (2) Genetic testing has confirmed homozygous or compound heterozygous ZMPSTE24 mutations (medical record required)
  • 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 OR (B) There is support for using the requested agent for the patient’s age
  • Body surface area ≥ 0.39 m^2
  • Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, geneticist) or 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
  • For members in Ohio who are Fully Insured or HIM Shop (SG): the same contraindication criterion applies AND ONE of the following: (1) patient has another FDA labeled indication, OR (2) indication supported in compendia, OR (3) prescriber has submitted two peer-reviewed journal articles supporting requested use (excluding case studies); acceptable compendia and literature sources include DrugDex level 1, 2A, 2B; AHFS-DI; NCCN 1 or 2A; Clinical Pharmacology; LexiDrugs evidence level A; or peer-reviewed medical literature

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) or has consulted with a specialist
  • Patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months