Harliku — Highmark

Preferred products

• Nityr 2 mg tablets

Initial criteria

• Member is age ≥ 18 years
• Diagnosis of AKU confirmed by either: 24-hour urine with elevated urine HGA based on laboratory reference range OR mutations in the HGD gene
• Member is using Harliku or Nityr 2 mg to reduce urine HGA
• If request is for Harliku, member has experienced therapeutic failure or intolerance to plan-preferred Nityr 2 mg tablets

Reauthorization criteria

• Member has experienced a reduction in urine HGA from baseline

Approval duration

12 months