Keveyis — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following:
• - The patient has a diagnosis of primary hypokalemic periodic paralysis, primary hyperkalemic periodic paralysis, or a related variant of familial periodic paralysis (e.g., congenital myasthenic syndrome, Andersen-Tawil syndrome, paramyotonia congenita, potassium-associated myotonia) AND BOTH of the following:
• - The patient has implemented and maintained dietary and lifestyle changes to help prevent episodes AND
• - ONE of the following:
• • The patient has tried and had an inadequate response to acetazolamide OR
• • The patient has an intolerance or hypersensitivity to acetazolamide OR
• • The patient has an FDA labeled contraindication to acetazolamide OR
• • The patient has another FDA approved indication for the requested agent
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• ALL of the following:
• - The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• - If the patient has a diagnosis of primary hypokalemic periodic paralysis, primary hyperkalemic periodic paralysis, or a related variant of familial periodic paralysis, the patient has continued to maintain dietary and lifestyle changes to help prevent episodes AND
• - The patient has had clinical benefit with the requested agent AND
• - The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 3 months; renewal 12 months