Prior Authorization : Services Requiring Prior Authorization

Voxzogo

Voxzogo requires clinical PA.

Clinical Criteria for Voxzogo

The following clinical criteria must be met and documented for approval of a PA request for Voxzogo:

• The member has achondroplasia.
• The member's current height, weight, and growth velocity has been provided.
• The provider has submitted evidence that the member has open epiphyses.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Voxzogo. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

If clinical criteria for Voxzogo are met, initial PA requests may be approved for up to 183 days.

Renewal PA Requests

Renewal PA requests for Voxzogo may be approved for up to 183 days. Renewal PA requests must include copies of the member's current medical records demonstrating that the member had an increase in their growth velocity compared to their baseline prior to the initiation of Voxzogo.

All renewal PA requests require the member to be adherent with the prescribed treatment regimen.

Submitting PA Requests for Voxzogo

PA requests for Voxzogo must be submitted using the PA/DGA form.

PA requests for Voxzogo must be completed, signed, and dated by the prescriber. PA requests for Voxzogo should be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The prescriber is required to send the completed PA/DGA form to the pharmacy where the prescription will be filled. The pharmacy provider is required to complete a PA/RF and submit it with the PA/DGA form received from the prescriber, to ForwardHealth using the PA submission option most appropriate for the drug.

PA requests for Voxzogo may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).