Orfadin (nitisinone) oral suspension — Highmark
Hereditary tyrosinemia type 1 (HT-1)
Preferred products
- generic nitisinone capsules
- Nityr tablets
Initial criteria
- Diagnosis of HT-1 confirmed by biochemical and/or genetic testing
- Prescriber attests that the member is following a diet restricted in tyrosine and phenylalanine
- For brand Orfadin capsules: member has experienced therapeutic failure or intolerance to ALL of the following: generic nitisinone capsules AND plan-preferred Nityr tablets
- For Orfadin oral suspension: member has experienced therapeutic failure or intolerance to ALL of the following plan-preferred products: generic nitisinone capsules AND Nityr tablets
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months