Duvyzat (givinostat oral suspension – ITF Therapeutics) — Cigna

Duchenne muscular dystrophy (DMD)

Initial criteria

Patient is age ≥ 6 years; AND
Patient’s diagnosis of Duchenne Muscular Dystrophy is confirmed by genetic testing with a confirmed pathogenic variant in the dystrophin gene [documentation required]; AND
Patient is ambulatory; AND
Patient is on a stable systemic corticosteroid therapy for at least 6 months; AND
Medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne muscular dystrophy and/or neuromuscular disorders

Patient is age ≥ 6 years; AND
Patient is ambulatory; AND
Patient is continuing to receive stable systemic corticosteroid therapy; AND
According to the prescriber, the patient continues to benefit from therapy, as demonstrated by a stabilization or slowed decline on timed function tests (e.g., 4-stair climb, 6-minute walk test, time-to-rise) or in the North Star Ambulatory Assessment (NSAA) score; AND
Medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne muscular dystrophy and/or neuromuscular disorders

1 year