Sohonos (palovarotene) — Point32Health

Initial criteria

• Documented diagnosis of fibrodysplasia ossificans progressive
• Documentation of genetic testing confirming the presence of the ACVR1 R206H mutation
• If female, age ≥ 8 years OR if male, age ≥ 10 years
• Prescribed by or in consultation with a physician who specializes in rare connective tissue diseases

Reauthorization criteria

• Documented diagnosis of fibrodysplasia ossificans progressive
• Documentation of genetic testing confirming the presence of the ACVR1 R206H mutation
• If female, age ≥ 8 years OR if male, age ≥ 10 years
• Prescribed by or in consultation with a physician who specializes in rare connective tissue diseases
• Documentation the patient has experienced a therapeutic response based on provider attestation (e.g., decrease in flares, decrease in HO volume, improved function and/or quality of life)

Approval duration

6 months initial, 6 months reauth