Zokinvy — Blue Cross Blue Shield of Oklahoma

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 LMNA variant producing progerin 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 OR (2) Genetic testing has confirmed homozygous or compound heterozygous ZMPSTE24 mutations
• If the patient has an FDA labeled indication, ONE of the following: (A) Age within FDA labeling for the indication OR (B) Support for using the agent for patient’s age for the indication
• Body surface area ≥ 0.39 m²
• Prescriber is a specialist (e.g., cardiologist, geneticist) or has consulted with a specialist
• Patient does NOT have FDA labeled contraindications to the agent

Reauthorization criteria

• Patient previously approved for the agent through 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 or has consulted with a specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months