Livmarli (maralixibat) — CareFirst (Caremark)
Cholestatic pruritus in Alagille syndrome (ALGS)
Initial criteria
- Member has a diagnosis of ALGS established by one of the following: genetic testing (e.g., JAG1 or NOTCH2 gene variants), family history of ALGS and one or more major clinical features of ALGS, bile duct paucity and three or more major clinical features of ALGS, or four or more major clinical features of ALGS
- Member has evidence of cholestasis (e.g., elevated serum bile acid level)
- Member does not have a history or presence of other concomitant liver disease (e.g., biliary atresia, progressive familial intrahepatic cholestasis [PFIC], liver cancer)
- Member has not received a liver transplant
- Member is age ≥ 3 months
- Medication must be prescribed by or in consultation with a hepatologist or gastroenterologist
- Medication will not be used concomitantly with any other ileal bile acid transporter (IBAT) inhibitor (e.g., Bylvay)
Reauthorization criteria
- Member is experiencing benefit from therapy (e.g., improvement in pruritus)
Approval duration
Initial: 6 months; Reauthorization: 12 months