nitisinone — CareFirst (Caremark)
Hereditary tyrosinemia type 1 (HT-1)
Initial criteria
- Diagnosis is confirmed by biochemical testing (e.g., detection of succinylacetone in urine), enzyme assay, or genetic testing
- Requested medication is being used as an adjunct to dietary restriction of tyrosine and phenylalanine
- Medication is prescribed by or in consultation with a physician who specializes in the treatment of enzyme or metabolic disorders
Reauthorization criteria
- Member is experiencing beneficial clinical response from therapy
- Indication remains as listed in the coverage criteria section
Approval duration
12 months