Rivfloza — CareFirst (Caremark)
Primary hyperoxaluria type 1 (PH1)
Initial criteria
- Member is age ≥ 2 years
- Diagnosis of PH1 confirmed by molecular genetic test demonstrating a mutation in the alanine:glyoxylate aminotransferase (AGXT) gene OR liver enzyme analysis demonstrating absent or significantly reduced alanine:glyoxylate aminotransferase (AGT) activity
- Member has relatively preserved kidney function (eGFR ≥ 30 mL/min/1.73 m2)
- Requested medication will not be used in combination with lumasiran
Reauthorization criteria
- Member continues to meet all initial criteria
- Member demonstrates a positive response to therapy (e.g., decrease or normalization in urinary and/or plasma oxalate levels, improvement in kidney function)
Approval duration
12 months