Daybue (trofinetide) — CareFirst (Caremark)

Initial criteria

• Member is 2 years of age or older.
• The diagnosis is confirmed by a pathogenic variant in the MECP2 gene.
• Member exhibits clinical manifestations of disease (e.g., hand wringing, apraxia, gait abnormalities, developmental delays).
• Medication must be prescribed by or in consultation with a physician who specializes in the treatment of Rett syndrome.

Reauthorization criteria

• Member is experiencing benefit from therapy (e.g., stabilization or improvement in repetitive movements, mood dysfunction/disruptive behavior, vocalization, ambulation).

Approval duration

12 months