Duvyzat (givinostat) — Highmark

Duchenne muscular dystrophy (DMD)

Initial criteria

age ≥ 6 years
diagnosis of Duchenne muscular dystrophy (ICD-10: G71.01) confirmed by a documented pathogenic mutation in the dystrophin gene
member is ambulatory
prescribed by or in consultation with a physician who specializes in treating neuromuscular disorders (e.g., neurologist)
member meets ONE of the following: 1) has been stable on corticosteroid therapy for at least 6 months AND will be using Duvyzat in combination with corticosteroid therapy; OR 2) has experienced contraindication or intolerance to corticosteroid therapy

prescriber attests that the member has experienced a positive clinical response to therapy
member continues to be ambulatory
member meets ONE of the following: 1) has been stable on corticosteroid therapy for at least 6 months AND will continue to use Duvyzat in combination with corticosteroid therapy; OR 2) has experienced contraindication or intolerance to corticosteroid therapy

12 months