Keveyis (dichlorphenamide tablets - Xeris, generic) — Cigna

Initial criteria

• Patient has a confirmed diagnosis of primary hypokalemic periodic paralysis by meeting at least ONE of the following (serum potassium concentration < 3.5 mEq/L during a paralytic attack; OR family history of the condition; OR genetically confirmed skeletal muscle calcium or sodium channel mutation); AND
• The prescriber has excluded other reasons for acquired hypokalemia (e.g., renal, adrenal, or thyroid dysfunction; renal tubular acidosis; diuretic or laxative abuse); AND
• Patient has had improvements in paralysis attack symptoms with potassium intake; AND
• Patient has tried oral acetazolamide therapy; AND
• According to the prescriber, acetazolamide therapy did not worsen the paralytic attack frequency or severity; AND
• The medication is prescribed by or in consultation with a neurologist or a physician who specializes in the care of patients with primary periodic paralysis (e.g., muscle disease specialist, physiatrist)

Reauthorization criteria

• Patient is currently receiving dichlorphenamide and has responded to dichlorphenamide (e.g., decrease in the frequency or severity of paralytic attacks) as determined by the prescriber

Approval duration

initial 2 months; renewal 1 year