CurrentColorado Rocky Mountain Health PlansPolicy N/A

Gattex (teduglutide) prior authorization

Defines prior authorization and reauthorization criteria for Gattex (teduglutide) for Colorado Rocky Mountain Health Plans members, including initial eligibility and documentation expectations for providers requesting coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyGattex (teduglutide) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 16, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Gattex; initial approvals issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

≥1 yrminimum age

SBScovered diagnosis

parenteral supportrequired condition

Coverage Criteria for Gattex (teduglutide)

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Initial Authorization Requirements

Initial Authorization

Initial authorization requirements

Initial Therapy: Diagnosis of Short Bowel Syndrome (SBS) AND member is dependent on parenteral support.

Authorization will be issued for 12 months.

Continuation Therapy / Reauthorization

Reauthorization rules

Continuation: Documentation of positive clinical response to Gattex (teduglutide) therapy for reauthorization.

Authorization will be issued for 12 months.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Gattex (teduglutide). Initial authorizations are issued for 12 months when criteria are met.

Initial authorization duration: 12 months
Prior authorization required

Note

Automated approval / prior claims

Automated approval or approval based on prior claims/medication history and diagnosis codes may be used at the payer's discretion. Use of automated approval and re-approval processes varies by program and therapeutic class.

Approval may be based solely on prior claims/medication history and ICD-10 diagnosis codes
Automated approval processes vary by program/therapeutic class

Documentation Required

Reauthorization documentation requirements

For reauthorization, documentation must show a positive clinical response to Gattex therapy. Reauthorizations are issued for 12 months. Expect supporting documentation such as clinical progress notes, medication/claims history, and appropriate diagnosis coding (Short Bowel Syndrome).

Reauthorization requirement: documentation of positive clinical response
Reauthorization duration: 12 months
Include claims/medication history and clinical notes; ensure ICD-10 diagnosis for SBS is present

Denial Risk

Denial risk — missing diagnosis or parenteral support dependency

Initial approval will not be met in the absence of a documented diagnosis of Short Bowel Syndrome (SBS) and dependency on parenteral support.

Absence of SBS diagnosis or parenteral support dependency = will not meet initial approval

Background

Gattex (teduglutide) is a glucagon-like peptide-2 (GLP-2) analog indicated for the treatment of adults and pediatric patients 1 year of age and older with Short Bowel Syndrome (SBS) who are dependent on parenteral support. Prior authorization is required; when the initial criteria are met authorization will be issued for 12 months.

Key Definitions

Short Bowel Syndrome (SBS) — definition and inclusion criteria

TermShort Bowel Syndrome (SBS)

InclusionClinical diagnosis for which Gattex (teduglutide) is indicated

Dependency requirementPatients must be dependent on parenteral support to meet coverage criteria

Age considerationIndication includes adults and pediatric patients ≥ 1 year of age

Coverage scopeTherapy for diagnoses other than SBS or patients not dependent on parenteral support are not covered under these criteria