Opfolda — CareFirst (Caremark)
Late-onset Pompe disease
Initial criteria
- Member is 18 years of age or older
- Member weighs greater than or equal to 40 kg
- Diagnosis was confirmed by enzyme assay demonstrating a deficiency of acid alpha-glucosidase enzyme activity or by genetic testing
- Member is not improving on current enzyme replacement therapy (ERT) (e.g., Lumizyme, Nexviazyme)
- The requested medication will be taken in combination with Pombiliti (cipaglucosidase alfa-atga)
Reauthorization criteria
- Member is responding to therapy (e.g., improvement, stabilization, or slowing of disease progression for motor function, walking capacity, respiratory function, or muscle strength)
- The requested medication will be taken in combination with Pombiliti (cipaglucosidase alfa-atga)
Approval duration
12 months