Keveyis — CareFirst (Caremark)
Primary hypokalemic periodic paralysis
Preferred products
- acetazolamide
Initial criteria
- Diagnosis supported by at least one of the following: genetic test results OR member has a family history of primary hypokalemic periodic paralysis OR member’s attacks are associated with hypokalemia AND both Andersen-Tawil syndrome and thyrotoxic periodic paralysis have been ruled out
- Member had a trial and suboptimal response to treatment with acetazolamide
Reauthorization criteria
- Member has demonstrated a response to therapy as evidenced by an improvement in their condition (e.g. decrease in the number or severity of attacks)
Approval duration
initial 60 days, continuation 12 months