sapropterin dihydrochloride — CareFirst (Caremark)
Autosomal dominant guanine triphosphate (GTP) cyclohydrolase deficiency (Segawa disease)
Initial criteria
- Member is age ≥ 1 month
- Diagnosis confirmed for one of the listed biopterin metabolic defects
- Medication prescribed by or in consultation with a physician who specializes in the treatment of metabolic disease and/or PKU
Reauthorization criteria
- Member experiencing benefit from therapy as evidenced by disease stability or improvement
Approval duration
Initial 6 months; reauthorization 6 months