Strensiq (asfotase alfa) — Highmark
perinatal/infantile-onset hypophosphatasia (HPP)
Initial criteria
- Strensiq is prescribed by or in consultation with a geneticist, endocrinologist, a metabolic disorder sub-specialist, or a provider who specializes in the treatment of perinatal/infantile- or juvenile-onset HPP
- Member has a documented diagnosis of perinatal/infantile- or juvenile-onset HPP supported by all of the following: documentation of ALPL gene mutation(s); serum alkaline phosphatase (ALP) level below the age-adjusted normal range per laboratory reference range; plasma pyridoxal-5’-phosphate (PLP) above the upper limit of normal per laboratory reference range
- Member has a documented history of onset of signs and symptoms of HPP prior to 18 years of age
Reauthorization criteria
- Prescriber attests that the member has experienced a positive clinical response to therapy
Approval duration
12 months