Jaythari (deflazacort tablets – Zydus Pharmaceuticals) — Cigna

Duchenne Muscular Dystrophy

Initial criteria

Patient is age ≥ 2 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 meets ONE of the following conditions (a or b):
a) Patient has tried prednisone or prednisolone for ≥ 6 months [documentation required] AND according to the prescriber, the patient has had at least ONE of the following significant intolerable adverse effects [(1), (2), (3), or (4)]:
(1) Cushingoid appearance [documentation required]; OR
(2) Central (truncal) obesity [documentation required]; OR
(3) Undesirable weight gain defined as ≥ 10% of body weight increase over a 6-month period [documentation required]; OR
(4) Diabetes and/or hypertension that is difficult to manage according to the prescriber [documentation required]; OR
b) According to the prescriber, the patient has experienced a severe behavioral adverse event while on prednisone or prednisolone therapy that has or would require a prednisone or prednisolone dose reduction [documentation required]; AND
The 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 ≥ 2 years; AND
Patient has tried prednisone or prednisolone [documentation required]; AND
According to the prescriber, the patient has responded to or continues to have improvement or benefit from deflazacort therapy [documentation required] (examples of improvement include improvements in motor function, muscle strength, pulmonary function, etc.); AND
The 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