CurrentMass General Brigham Health PlanPolicy N/A

Zorbtive (somatropin) — Coverage Criteria (short bowel syndrome)

Policy governs prior authorization and coverage criteria for Zorbtive (somatropin) for treatment of adult short bowel syndrome (SBS) for members under the Mass General Brigham Health Plan pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyZorbtive (somatropin) — Coverage Criteria (short bowel syndrome)

Policy CodePolicy N/A

Change TypeAdministrative update (SGM → Custom)

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization under the pharmacy benefit and provide documentation of dependence on parenteral nutrition or evidence the member is currently receiving therapy.

SourceLink

POLICY UPDATE CHANGES

Policy was switched from SGM to Custom following review at the December P&T committee.

01/01/2024policy effective date

FDA-onlycoverage limited to

4 weeksapproval duration

Coverage Criteria

Initial Authorization Criteria

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FDA Indication: Treatment is for short bowel syndrome in adult patients receiving specialized nutritional support (FDA‑approved indication).

All other indications are considered experimental/investigational and not medically necessary.

Member status: Member is either new to the plan and currently receiving the requested medication (excluding samples or manufacturer's patient assistance program supply) OR is dependent on parenteral nutrition support for SBS.

Documentation required to support ongoing treatment or dependence on parenteral nutrition.

Continuation Therapy

Continuation of therapy

Continuation requirements: All members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria.

Documentation that continuation requests meet initial authorization criteria is required.

Initial Therapy

Initial authorization may be granted when:

Existing treatment on enrollment: Member is new to the plan but currently receiving the requested medication (excluding samples or manufacturer's patient assistance program supply).

Documentation of ongoing treatment required.

Dependence on parenteral nutrition: Member is being treated for short bowel syndrome and is dependent on parenteral nutrition support.

Clinical documentation required.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required — Prior authorization is required under the pharmacy benefit

Prior authorization is required under the pharmacy benefit. Authorization may be granted for members new to the plan who are currently receiving the medication (excluding product obtained as samples or via manufacturer patient assistance programs).

Pharmacy benefit prior authorization required
Contact phone: 800-711-4555; Fax: 844-403-1029

Note

Provider action highlight

Documentation Required

Clinical Documentation Required

Documentation that the member is dependent on parenteral nutrition support for short bowel syndrome (SBS) is required. For continuation requests, documentation must show the member continues to meet all initial authorization criteria.

Document dependence on parenteral nutrition support for SBS
Continuation requests must meet all initial authorization criteria

Denial Risk

Non‑FDA Indications Not Covered

Requests for indications other than the FDA‑approved treatment of short bowel syndrome in adults receiving specialized nutritional support are not covered.

Non‑FDA indications are considered experimental/investigational and not medically necessary

Denial Risk

New Member Initiation Limit

New members currently not receiving the medication may not qualify for initiation of therapy unless they meet the stated criteria or were previously treated and currently receiving the medication as described.

New member initiation limited — authorization may be granted only for new members currently receiving treatment as described

Background

Short bowel syndrome (SBS) is a condition in which patients have insufficient intestinal length or function and may require specialized nutritional support, including parenteral nutrition. Zorbtive (somatropin) is FDA‑approved to treat adult patients with SBS who are receiving specialized nutritional support to reduce dependence on parenteral nutrition.

Revision History

2024-01-01policy_effective_dateLatest

Policy became effective as a custom policy after being switched from SGM following the December P&T review.

2023-12-13policy_review

Reviewed at the December P&T committee and decision made to switch the policy from SGM to Custom effective 01/01/2024.