Agamree (vamorolone) — Highmark
Duchenne muscular dystrophy (DMD)
Initial criteria
- Diagnosis of DMD (ICD-10: G71.01)
- Diagnosis of DMD confirmed by a mutation of the dystrophin gene
- Member is ambulatory
- Medication is prescribed by or in consultation with a physician who specializes in treating neuromuscular disorders (e.g., neurologist)
- Member has experienced a delay or decline in growth while on prednisone that is not expected to occur with Agamree
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months