miglustat — CareFirst (Caremark)

Initial criteria

• The diagnosis of Gaucher disease was confirmed by enzyme assay demonstrating a deficiency of beta-glucocerebrosidase (glucosidase) enzyme activity or by genetic testing
• The member has a documented inadequate response to, intolerable adverse events with, or a clinical reason to not use enzyme replacement therapy (e.g., allergy, hypersensitivity, poor venous access)

Reauthorization criteria

• The diagnosis of Gaucher disease was confirmed by enzyme assay demonstrating a deficiency of beta-glucocerebrosidase (glucosidase) enzyme activity or by genetic testing
• Member is not experiencing an inadequate response or any intolerable adverse events from therapy

Approval duration

12 months