iptacopan hcl cap 200 MG — Blue Cross Blue Shield of Kansas

Initial criteria

• Diagnosis of PNH confirmed by flow cytometry with at least 2 independent flow cytometry reagents on at least 2 cell lineages (e.g., RBCs and WBCs) demonstrating that the patient’s peripheral blood cells are deficient in glycosylphosphatidylinositol (GPI)-linked proteins
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist) or has consulted with a specialist
• The agent will NOT be used in combination with Empaveli (pegcetacoplan), Soliris (eculizumab), Bkemv (eculizumab-aeeb), Epysqli (eculizumab-aagh), Ultomiris (ravulizumab-cwvz), or Piasky (crovalimab-akkz)
• The patient does NOT have any FDA-labeled contraindications to Fabhalta

Approval duration

6 months