deflazacort — CareFirst (Caremark)

Preferred products

• prednisone
• prednisolone

Initial criteria

• The diagnosis of DMD was confirmed by one of the following criteria: genetic testing demonstrating a mutation in the DMD gene OR muscle biopsy demonstrating absent dystrophin.
• Member is age ≥ 2 years.
• Member has tried prednisone or prednisolone and experienced unmanageable and clinically significant weight gain/obesity or psychiatric/behavioral issues (e.g., abnormal behavior, aggression, irritability).
• For weight gain/obesity: body mass index is in the overweight or obese category while receiving treatment with prednisone or prednisolone.
• Medication must be prescribed by or in consultation with a physician who specializes in the treatment of DMD.
• Laboratory confirmation of DMD diagnosis by genetic testing or muscle biopsy must be submitted.
• Chart documentation of weight gain/obesity or persistent psychiatric/behavioral issues with previous prednisone or prednisolone treatment must be provided.

Reauthorization criteria

• Member meets all initial coverage criteria.
• Member is receiving a clinical benefit from therapy with the requested medication (e.g., improvement or stabilization of muscle strength or pulmonary function).

Approval duration

Initial: 6 months; Reauthorization: 12 months