Vijoice (alpelisib tablets and oral granules - Novartis) — Cigna

Initial criteria

• Patient is age ≥ 2 years; AND
• Patient has at least one severe clinical manifestation of PROS, as determined by the prescriber; AND
• Patient has a PIK3CA mutation as confirmed by genetic testing; AND
• Medication is being prescribed by or in consultation with a physician that specializes in treatment of genetic disorders

Reauthorization criteria

• Patient has been established on Vijoice for at least 6 months; AND
• Patient has experienced a reduction in volume from baseline (prior to initiating Vijoice) in at least one lesion, as confirmed by measurement; AND
• Patient has experienced an improvement in at least one sign or symptom of PROS from baseline (prior to initiating Vijoice)

Approval duration

initial: 6 months; renewal: 1 year