Empaveli — Cigna

Initial criteria

• Patient age ≥ 18 years; AND
• Diagnosis confirmed by peripheral blood flow cytometry showing absence or deficiency of glycosylphosphatidylinositol-anchored proteins on at least two cell lineages; AND
• For a patient transitioning to Empaveli from eculizumab intravenous infusion (Soliris, biosimilar), prescriber attests that eculizumab will be discontinued 4 weeks after starting Empaveli; AND
• Medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• Patient age ≥ 18 years; AND
• According to the prescriber, patient is continuing to derive benefit from Empaveli (e.g., increased or stabilized hemoglobin levels, decreased transfusion needs, reductions in hemolysis, improvement in FACIT-Fatigue score); AND
• Medication is prescribed by or in consultation with a hematologist

Approval duration

6 months initial, 1 year reauth