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

nephropathic cystinosis

Preferred products

ONE of the following: (A) patient has a diagnosis of nephropathic cystinosis OR (B) patient has another FDA labeled indication for the requested agent and route of administration OR (C) patient has an indication supported in compendia for the requested agent and route of administration
If the patient has an FDA labeled indication, ONE of the following: (A) patient’s age is within FDA labeling for the requested indication OR (B) there is support for using the requested agent for the patient’s age for the requested indication
ONE of the following: (A) patient has tried and had an inadequate response to Cystagon (immediate release cysteamine) OR (B) patient has intolerance or hypersensitivity to Cystagon not expected with the requested agent OR (C) patient has an FDA labeled contraindication to Cystagon not expected with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) OR has consulted with a specialist in the area of the patient’s diagnosis
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months