Cystadane (betaine anhydrous for oral solution) — Highmark

Preferred products

• betaine anhydrous powder (generic)

Initial criteria

• Diagnosis of one of the following: Cystathionine beta-synthase (CBS) deficiency, 5,10-methylenetetrahydrofolate reductase (MTHFR) deficiency, or Cobalamin cofactor metabolism (cbl) defect
• If the request is for brand Cystadane, the member has experienced therapeutic failure or intolerance to generic betaine anhydrous powder

Reauthorization criteria

• The member has experienced a reduction in total homocysteine plasma concentrations from baseline
• If the request is for brand Cystadane, the member has experienced therapeutic failure or intolerance to generic betaine anhydrous powder

Approval duration

12 months