CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Voxzogo (vosoritide) — Coverage Criteria for Achondroplasia

Policy governing coverage and authorization criteria for vosoritide (Voxzogo) to increase linear growth in pediatric patients with achondroplasia for Neighborhood Health Plan of Rhode Island Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoxzogo (vosoritide) — Coverage Criteria for Achondroplasia

Policy CodePolicy N/A

Change TypeNo material change

Effective Date05/01/2022

Next Review DateN/A

Key ActionObtain prior authorization for a 12-month approval when all listed clinical criteria (including FGFR3 genetic confirmation, open epiphyses, and AGV ≥ 1.5 cm/year) are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period

AGV ≥ 1.5 cm/yrminimum AGV

requiredgenetic confirmation

1 vial/daydosing limit

Coverage and Medical Necessity Criteria

Initial Therapy

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoxzogo (vosoritide) — Coverage Criteria for Achondroplasia

Policy CodePolicy N/A

Change TypeNo material change

Effective Date05/01/2022

Next Review DateN/A

Key ActionObtain prior authorization for a 12-month approval when all listed clinical criteria (including FGFR3 genetic confirmation, open epiphyses, and AGV ≥ 1.5 cm/year) are met.

SourceLink

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ref":"b0_0","title":"Initial Therapy"},{

citations":["3"],"intro":"Authorization of 12 months may be granted for continuation when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Continuation Approval\",\"text\":\"Chart note documentation showing the patient has open epiphyses AND a current annualized growth velocity (AGV) >= 1.5 cm/year\",\"threshold\":\"AGV >= 1.5 cm/year\",\"note\":\"Approval duration: 12 months\",\"children\":[]}"],

ref":"b0_1","title":"Continuation Therapy"},{

citations":["1"],"intro":"","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Non-covered Indications\",\"text\":\"All indications other than the FDA‑approved indication to increase linear growth in pediatric patients with achondroplasia who have open epiphyses are considered experimental/investigational and not medically necessary.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_2","title":"Not Medically Necessary / Investigational Uses"}]}{

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Prior Authorization, Documentation, and Prescribing Rules

Prior Authorization

Initial prior authorization — 12-month approval when all criteria met

Prior authorization is required for initial treatment and, when granted, will authorize therapy for 12 months only when all listed clinical criteria are met (including genetic confirmation of FGFR3 mutation, prescriber specialty, documentation of AGV, evidence of open epiphyses, absence of disallowed therapies in past 6 months, and no planned limb-lengthening surgery).

Prior Authorization

Continuation prior authorization — 12 months with documented ongoing benefit

Prior authorization is required for continuation and may be granted for 12 months when chart documentation shows the patient has open epiphyses and a current annualized growth velocity (AGV) ≥ 1.5 cm/year.

Step Therapy

Therapy exclusion window — no GH/IGF‑1/anabolic steroids in prior 6 months

Do not authorize if the patient has received growth hormone, insulin-like growth factor 1, or anabolic steroids within the past 6 months; receipt of these therapies within 6 months is exclusionary to approval.

Documentation Required

Required clinical documentation — genetic test, AGV, open epiphyses, and prescriber specialty

Providers must include chart documentation confirming achondroplasia diagnosis by FGFR3 genetic testing, recent annualized growth velocity (AGV), evidence of open epiphyses, and prescriber specialty; for continuation, include documentation of continued AGV ≥ 1.5 cm/year and open epiphyses.

Denial Risk

Indication restriction — non‑achondroplasia uses not covered

Use of vosoritide for any indication other than increasing linear growth in pediatric patients with achondroplasia who have open epiphyses is considered experimental/investigational and not medically necessary.

Denial Risk

Criteria noncompliance — denial triggers

Applications lacking FGFR3 genetic confirmation, showing AGV below the required threshold, documenting closed epiphyses, indicating recent use of disallowed therapies, or listing planned/expected limb‑lengthening surgery are triggers for denial.

No genetic confirmation of FGFR3 mutation
AGV < 1.5 cm/year
Closed epiphyses
Received growth hormone, IGF‑1, or anabolic steroids in past 6 months
Planned or expected limb‑lengthening surgery

OpenPayer

Voxzogo (vosoritide) — Coverage Criteria for Achondroplasia

Coverage and Medical Necessity Criteria

Product Coding, Quantity Limits, and Key Measures

Prior Authorization, Documentation, and Prescribing Rules

Background and Regulatory Status

Key Definitions