vosoritide — Blue Cross Blue Shield of Texas

Initial criteria

• The patient has a diagnosis of achondroplasia confirmed by genetic testing OR radiographic findings AND the requested agent will be used to increase linear growth AND imaging shows the patient does not have closed epiphyses if female age > 12 years or male age > 14 years [medical records required] OR the patient has another FDA labeled indication for the requested agent and route of administration
• If the patient has an FDA labeled indication, ONE of the following: the patient's age is within FDA labeling for the requested indication OR there is support for using the agent for the patient's age for the requested indication
• 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

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Imaging shows the patient does not have closed epiphyses if female age > 12 years or male 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

Approval duration

12 months