Cystadane powder — Cigna
homocystinuria to decrease elevated homocysteine blood concentrations in pediatric and adult patients
Preferred products
- generic betaine anhydrous powder
Initial criteria
- Patient meets the standard Metabolic Disorders – Betaine Anhydrous PA Policy criteria; AND
- Patient has tried generic betaine anhydrous powder [documentation required]; AND
- Patient cannot continue to use the Preferred Product due to a formulation difference in the inactive ingredient(s) (e.g., differences in the stabilizing agent, buffering agent, and/or surfactant) which, according to the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
1 year