Pyrukynd (mitapivat tablets) — Cigna

Initial criteria

• Patient age ≥ 18 years; AND
• Presence of at least two variant/mutant alleles in the pyruvate kinase liver and red blood cell (PKLR) gene [documentation required]; AND
• At least one of the variant/mutant alleles is a missense variant [documentation required]; AND
• Patient has ONE of the following (a or b): a) current hemoglobin level ≤ 10 g/dL; OR b) currently receiving red blood cell transfusions regularly, defined as at least six transfusions within the last year; AND
• Medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• Patient age ≥ 18 years; AND
• Presence of at least two variant/mutant alleles in the pyruvate kinase liver and red blood cell (PKLR) gene [documentation required]; AND
• At least one of the variant/mutant alleles is a missense variant [documentation required]; AND
• According to the prescriber, patient has experienced a benefit from therapy based on ONE of the following (a, b, or c): a) increase in or maintenance of hemoglobin levels; OR b) improvement in or maintenance of hemolysis laboratory parameters; OR c) decrease in or maintenance of transfusion requirements; AND
• Medication is prescribed by or in consultation with a hematologist

Approval duration

initial: 6 months; reauth: 1 year