Pharmacy Prior Authorization Criteria

Veopoz (pozelimab-bbfg)

Indications for Prior Authorization

Veopoz (pozelimab-bbfg)

• For diagnosis of CD55-deficient protein-losing enteropathy (PLE)
  Indicated for the treatment of adult and pediatric patients 1 year of age and older with CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease.

Criteria

Veopoz

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of active CD55-deficient protein-losing enteropathy (PLE), also known as CHAPLE disease
AND
• Patient has a confirmed genotype of biallelic CD55 loss-of-function mutation
AND
• Patient is 1 year of age or older
AND
• Patient has hypoalbuminemia (serum albumin concentration of less than or equal to 3.2 g/dL)
AND
• Patient has at least one of the following signs or symptoms within the last six months:
• abdominal pain
• diarrhea
• peripheral edema
• facial edema
AND
• Prescribed by or in consultation with one of the following:
• Immunologist
• Geneticist
• Hematologist
• Gastroenterologist

Veopoz

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g. decrease in albumin transfusions and hospitalizations, normalization of serum IgG concentrations, etc.)

P & T Revisions

2024-09-23, 2023-12-08, 2023-11-06, 2023-09-29

References

1. Veopoz Prescribing Information. Regeneron Pharmaceuticals, Inc. Tarrytown, NY. March 2024.

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Revision History

• 2024-09-23: 2024 UM Annual Review. Updated reauth criteria to standard "patient demonstrates positive clinical response to therapy." Background updates
• 2023-12-08: Addition of EHB formulary. No changes to criteria.
• 2023-11-06: Addition of gastroenterologist to specialist option
• 2023-09-29: New Program for Veopoz

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