Endari (L-glutamine oral powder) — CareFirst (Caremark)

To reduce the acute complications of sickle cell disease in adult and pediatric patients age ≥ 5 years

Initial criteria

Prescription must be by or in consultation with a hematologist or specialist in sickle cell disease
Member age ≥ 5 years
Indicated for reducing acute complications of sickle cell disease
Member has sickle hemoglobin C (HbSC) or sickle β+-thalassemia (HbSβ+) genotype OR
Member has homozygous hemoglobin S (HbSS) or sickle β0-thalassemia (HbSβ0) genotype AND any of the following:
1. Has experienced an inadequate response or intolerance to hydroxyurea
2. Has a contraindication to hydroxyurea
3. Will be using Endari with concurrent hydroxyurea therapy

Member has experienced a reduction in acute complications of sickle cell disease (e.g., reduction in painful vaso-occlusive episodes, acute chest syndrome episodes, fever, occurrences of priapism, splenic sequestration) since initiating Endari therapy

12 months