Procysbi (cysteamine bitartrate) — Blue Cross Blue Shield of Alabama

Nephropathic cystinosis

Preferred products

ONE of the following:
- The patient has a diagnosis of nephropathic cystinosis OR
- The patient has another FDA labeled indication for the requested agent and route of administration OR
- The patient has an indication that is supported in compendia for the requested agent and route of administration
AND if the patient has an FDA labeled indication, then ONE of the following:
- The patient’s age is within FDA labeling for the requested indication OR
- There is support for using the requested agent for the patient’s age for the requested indication
AND ONE of the following:
- The patient has tried and had an inadequate response to Cystagon (immediate-release cysteamine) OR
- The patient has an intolerance or hypersensitivity to Cystagon that is not expected to occur with the requested agent OR
- The patient has an FDA labeled contraindication to Cystagon that is not expected to occur with the requested agent
AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with such a specialist
AND The patient does NOT have any FDA-labeled contraindications to the requested agent

12 months