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The Policy VaultThe Policy Vault

vosoritide — Blue Cross Blue Shield of Oklahoma

achondroplasia

Initial criteria

  • 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): genetic testing OR radiographic findings
  • 2. The requested agent will be used to increase linear growth
  • 3. Imaging indicates the patient does not have closed epiphyses if the member is female and age > 12 years or if the member is male and age > 14 years [medical records required]
  • OR B. The patient has another FDA labeled indication for the requested agent and route of administration
  • AND 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
  • AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with such a specialist
  • AND the patient will NOT be using the requested agent in combination with another growth hormone agent for the requested indication
  • AND the patient does NOT have any FDA labeled contraindications to the requested agent
  • Length of Approval: 12 months
  • ALTERNATIVELY, approval when:
  • 1. The member resides in Ohio AND
  • 2. 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 peer-reviewed journal articles supporting the proposed use as generally safe and effective (randomized, double-blind, placebo-controlled trials preferred; case studies not acceptable)

Reauthorization criteria

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

Approval duration

12 months