PHARMACY POLICY STATEMENT Akansas PASSE
Pharmacy benefit policy describing prior authorization criteria, age/weight limits, diagnosis requirements, dosing, initial and reauthorization durations, and exclusions for Gattex (teduglutide) for members with short bowel syndrome dependent on parenteral support.
New policy for Gattex created 06/29/2020; revised 01/05/2022 to include baseline weekly volume of parenteral support reference.
Coverage Summary
Coverage stance: covered_with_criteria under the pharmacy benefit for Gattex (teduglutide) for treatment of short bowel syndrome (SBS) when the member is dependent on parenteral support and all prior authorization criteria are met. Scope summary: Pharmacy benefit policy requiring prior authorization and clinical documentation of SBS dependent on parenteral support, with age/weight limits (member must be ≥ 1 year of age and weigh ≥ 10 kg (22 pounds)), documented diagnosis of SBS with dependence on parenteral support, dose calculated using documented weight at 0.05 mg/kg once daily, initial approval for 6 months and reauthorization for 12 months. Exclusions: treatment of diseases not listed in the policy (not medically necessary).
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