Keveyis — Cigna
primary hypokalemic periodic paralysis (HypoPP)
Preferred products
- dichlorphenamide
Initial criteria
- Patient meets the standard Dichlorphenamide Prior Authorization Policy criteria; AND
- Patient has tried generic dichlorphenamide [documentation required]; AND
- Patient cannot continue to use generic dichlorphenamide tablets due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].
Approval duration
per Dichlorphenamide Prior Authorization Policy