resmetirom — Blue Cross Blue Shield of Texas

metabolic dysfunction associated steatohepatitis (MASH)

Initial criteria

Diagnosis of noncirrhotic NASH or MASH (medical records required)
Stage F2 or F3 fibrosis confirmed by BOTH: (A) FIB-4 score consistent with stage F2 or F3 fibrosis adjusted for age AND (B) ONE of: liver biopsy within past 2 years, vibration-controlled transient elastography (VCTE, e.g., Fibroscan), enhanced liver fibrosis (ELF) score, or magnetic resonance elastography (MRE)
If patient has FDA labeled indication, ONE of: (A) Age is within FDA labeling for the requested indication OR (B) Support for use outside labeled age
Alcohol consumption limits: if female < 20 grams/day OR if male < 30 grams/day
Patient being monitored and/or treated for comorbid conditions (e.g., cardiovascular disease, diabetes, dyslipidemia, hypertension)
Patient currently on a weight management regimen of low-calorie diet, increased physical activity, and behavioral modifications AND will continue this regimen with requested agent
Patient does NOT have ANY of: decompensated cirrhosis; moderate to severe hepatic impairment (Child-Pugh Class B or C); any other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis)
Prescriber is a specialist in area of patient’s diagnosis (e.g., hepatologist, gastroenterologist) or has consulted with one
No FDA labeled contraindications to the requested agent

Previously approved for requested agent through plan’s prior authorization process
Alcohol consumption within limits: female < 20 grams/day OR male < 30 grams/day
Patient currently on and will continue weight management regimen (low-calorie diet, increased physical activity, behavioral modifications)
Patient does NOT have ANY of: decompensated cirrhosis; moderate to severe hepatic impairment (Child-Pugh Class B or C); any other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis)
Patient has had clinical benefit with requested agent
Prescriber is a specialist in area of diagnosis or has consulted with one
No FDA labeled contraindications to requested agent

12 months