Gattex (teduglutide) — CareFirst (Caremark)

Short bowel syndrome (SBS) in adult and pediatric patients 1 year of age and older who are dependent on parenteral support

Initial criteria

Authorization of 6 months may be granted for treatment of short bowel syndrome if either of the following criteria are met:
• Adult members dependent on parenteral nutrition and/or intravenous (IV) fluids for at least 12 months and are receiving parenteral nutrition and/or IV fluids at least 3 times a week.
• Members less than 18 years of age receiving parenteral nutrition and/or IV fluids to account for at least 30% of caloric and/or fluid/electrolyte needs.

Authorization of 6 months may be granted for continued treatment in members requesting reauthorization when either of the following is met:
• The member remains dependent on parenteral nutrition and/or intravenous (IV) fluids and the requirement for parenteral support has decreased by at least 20% from baseline while on therapy with the requested drug.
• The member was previously dependent on parenteral nutrition and/or IV fluids and have been able to wean off the requirement for parenteral support while on therapy with the requested drug.

6 months