eliglustat — Blue Cross Blue Shield of Texas

Gaucher disease type 1 (GD1)

Initial criteria

ONE of the following: A. continuation of therapy if patient treated within past 90 days and at risk if changed OR B. ALL of the following:
Diagnosis of Gaucher disease type 1 (GD1)
Baseline glucocerebrosidase enzyme activity ≤ 15% of mean normal OR genetic analysis confirms two pathogenic GBA alleles
Patient age within FDA labeling or supported for use at that age
No neuronopathic symptoms indicative of Gaucher disease type 2 or type 3 (e.g., bulbar signs, pyramidal signs, oculomotor apraxia, seizures, dementia, ataxia)
At least one of: anemia, thrombocytopenia, hepatomegaly, splenomegaly, growth failure, or bone disease
Patient is CYP2D6 EM, IM, or PM by FDA-cleared test
Prescriber is a specialist (e.g., endocrinologist, geneticist) or has consulted a specialist
Patient will not use in combination with another substrate reduction therapy (e.g., Opfolda, miglustat, Zavesca)
No FDA labeled contraindications

Patient previously approved through plan's Prior Authorization process
Clinical benefit with requested agent
Prescriber is a specialist (e.g., endocrinologist, geneticist) or has consulted a specialist
Patient will not use in combination with another substrate reduction therapy agent (e.g., Opfolda, miglustat, Zavesca)
Patient has no FDA labeled contraindications

12 months