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Yorvipath (palopegteriparatide) — Blue Cross Blue Shield of Oklahoma

hypoparathyroidism

Initial criteria

  • ONE of the following:
  • A. ALL of the following:
  • 1. The patient has a diagnosis of hypoparathyroidism AND
  • 2. The patient does NOT have acute post-surgical hypoparathyroidism AND
  • 3. The patient does NOT have pseudohypoparathyroidism AND
  • 4. 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
  • 5. The patient has baseline (prior to therapy with the requested agent) albumin-corrected serum calcium ≥ 7.8 mg/dL using calcium and active vitamin D treatment AND
  • 6. The patient has baseline (prior to therapy with the requested agent) vitamin D levels above the lower limit of normal AND
  • 7. The patient has tried and had an inadequate response to maximally tolerated calcium AND vitamin D supplements (e.g., calcitriol, ergocalciferol, cholecalciferol) AND
  • 2. The patient will continue calcium and vitamin D supplementation while titrating to an appropriate dose of the requested agent AND
  • 3. The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, and Sensipar (cinacalcet) for the requested indication AND
  • 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • 2. The patient has an albumin-corrected total serum calcium concentration between 8.3 to 10.6 mg/dL AND
  • 3. The patient has had clinical benefit with the requested agent AND
  • 4. The patient will NOT be using the requested agent in combination with denosumab, estrogen, raloxifene, and Sensipar (cinacalcet) for the requested indication AND
  • 5. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  • 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

36 months (BCBSOK); 12 months (other plans)