Keveyis — Cigna

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