Sucraid (sacrosidase oral solution – QOL Medical) — Cigna

Initial criteria

• The diagnosis is established by ONE of the following (i or ii):
• i. Patient has endoscopic biopsy of the small bowel with disaccharidase levels consistent with congenital sucrase-isomaltase deficiency as evidenced by ALL of the following (a, b, c, and d):
• a) Decreased (usually absent) sucrase level (normal reference: > 25 U/g protein); AND
• b) Decreased or normal isomaltase (palatinase) level [normal reference: > 5 U/g protein]; AND
• c) Decreased maltase level (normal reference: > 100 U/g protein); AND
• d) Decreased or normal lactase level (normal reference: > 15 U/g protein); OR
• ii. Patient has a molecular genetic test demonstrating homozygous or compound heterozygous pathogenic or likely pathogenic sucrase-isomaltase gene variant; AND
• Prior to starting therapy with Sucraid, patient had symptomatic congenital sucrose-isomaltase deficiency (e.g., diarrhea, bloating, abdominal cramping); AND
• The medication is prescribed by or in consultation with a geneticist, gastroenterologist, a metabolic disorder sub-specialist, or a physician who specializes in the treatment of congenital diarrheal disorders.

Approval duration

1 year