Cystagon (cysteamine bitartrate) — CareFirst (Caremark)

Initial criteria

• Diagnosis of cystinosis confirmed by the presence of increased cystine concentration in leukocytes or by genetic testing
• Member will not use Cystagon in combination with Procysbi
• Medication must be prescribed by or in consultation with a physician who specializes in the treatment of metabolic disease and/or lysosomal storage disorders

Reauthorization criteria

• Member is responding to therapy (e.g., improvement, stabilization, or slowing of disease progression for serum creatinine, calculated creatinine clearance, leukocyte cystine concentration, or maintained growth [height])

Approval duration

12 months