Subject: Zorbtive 2244-A SGM P2022
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and
compendial uses are considered a covered benefit provided
that all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
FDA-Approved Indication
Zorbtive is indicated for the treatment of short bowel syndrome
in adult patients receiving specialized nutritional support.
Zorbtive should be used in conjunction with optimal
management of short bowel syndrome.
All other indications are considered
experimental/investigational and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
Short bowel syndrome (SBS)
Authorization of a total duration of 4 weeks may be granted to
members who depend on parenteral nutrition support who are
prescribed Zorbtive for the treatment of SBS.
III. CONTINUATION OF THERAPY
All members (including new members) requesting authorization
for continuation of therapy must meet all initial authorization
criteria.
Place of Service:
Outpatient
The above policy is based on the following references:
- Zorbtive [package insert]. Rockland, MA: EMD Serono, Inc.; September 2019.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
December 11, 2022
