Provider Alert! Prior authorization criteria for Voxzogo (Vosoritide)

Date: June 15, 2022

Attention: All Providers

Subject: Prior authorization criteria for Voxzogo (Vosoritide)

Effective Date: July 15, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Effective July 15, 2022, Texas Children’s Health Plan (TCHP) will implement the Voxzogo clinical edit in-line with the Health and Human Services Commission’s (HHSC) criteria. Voxzogo is a medication used to increase linear growth in children with achondroplasia who are 5 years of age and older with open epiphyses.

How this impacts providers: Effective July 15, 2022, prior authorization approval for Voxzogo will be considered once all the following criteria are met:

1. Does the client have diagnosis of achondroplasia confirmed with genetic testing? [Manual]

[ ] Yes (Go to #2) [ ] No (Deny)

2. Is this a renewal request?

[ ] Yes (Go to #4) [ ] No (Go to #3)

3. Is the client greater than or equal to (≥) 5 years of age?

[ ] Yes (Go to #4) [ ] No (Deny)

4. Does the client have open epiphyses? [Manual]

[ ] Yes (Go to #5) [ ] No (Deny)

5. Does the client have an annualized growth velocity (AGV) greater than or equal to (≥) 1.5 cm/year? [Manual]

[ ] Yes (Go to #6) [ ] No (Deny)

6. Does the client have an eGFR < 60 mL/min/1.73m² (CKD stages 3, 4 and 5)?

[ ] Yes (Deny) [ ] No (Approve – 365 days)

The following drugs will require a prior authorization:

Next steps for providers: Providers can find prior authorization form for Voxzogo on Navitus page beginning July 15, 2022. Prescribers should also adjust their prescribing patterns accordingly and share this update with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers