Endari (L-glutamine) — Highmark

Preferred products

• plan-preferred hydroxyurea

Initial criteria

• age ≥ 5 years
• diagnosis of sickle cell disease (ICD-10: D57)
• history of at least two sickle cell acute complications (e.g., vaso-occlusive crises, acute anemia, acute chest syndrome, etc.) within the previous 12 months
• therapeutic failure or intolerance to one over-the-counter L-glutamine product
• AND one of the following: (1) therapeutic failure, contraindication, or intolerance to plan-preferred hydroxyurea OR (2) Endari used in addition to hydroxyurea
• if request is for brand Endari, therapeutic failure or intolerance to generic prescription L-glutamine

Reauthorization criteria

• prescriber attests member has experienced therapeutic response defined as either (1) stability in sickle cell acute complications (e.g., VOCs, acute anemia, acute chest syndrome, etc.) OR (2) decrease in the number of sickle cell acute complications
• if request is for brand Endari, therapeutic failure or intolerance to generic prescription L-glutamine

Approval duration

12 months