Gattex (teduglutide) — Highmark

Initial criteria

• Approval may be granted when ONE of the following is met:
• A. age ≥ 18 years AND all of the following:
• 1. Diagnosis of short bowel syndrome;
• 2. Dependent on parenteral/intravenous nutrition support for at least 12 months;
• 3. Requires parenteral/intravenous nutrition at least three times per week;
• 4. Prescriber attests that colonoscopy of the entire colon with removal of polyps was completed within 6 months prior to initiation of therapy;
• OR
• B. age between 1 year and 17 years AND all of the following:
• 1. Weight ≥ 10 kg;
• 2. Diagnosis of short bowel syndrome;
• 3. Dependent on parenteral/intravenous nutrition support for at least 12 months;
• 4. Prescriber attests that a fecal occult blood test was performed within 6 months prior to initiation of therapy.

Reauthorization criteria

• All of the following:
• A. Member has experienced a reduction of at least 20% in parenteral/intravenous support volume from baseline;
• B. ONE of the following:
• 1. Member continues to be dependent on parenteral/intravenous nutrition support;
• OR
• 2. Member is not receiving parenteral/intravenous nutrition support and experienced therapeutic failure when Gattex was discontinued (member achieved enteral autonomy while taking Gattex and required reintroduction of parenteral/intravenous nutrition after discontinuing Gattex).

Approval duration

initial up to 6 months (Delaware Commercial fully‑insured and ACA members: 12 months); reauthorization up to 12 months