Ormalvi (dichlorphenamide) — Highmark

Preferred products

• generic dichlorphenamide

Initial criteria

• age ≥ 18 years
• member has one of the following diagnoses: primary hyperkalemic periodic paralysis and related variants OR primary hypokalemic periodic paralysis and related variants
• prescriber attests to the baseline number of muscle weakness attacks per week
• if the request is for brand Keveyis or Ormalvi, the member has experienced therapeutic failure or intolerance to generic dichlorphenamide

Reauthorization criteria

• prescriber attests that the member has experienced a decrease from baseline in the number of muscle weakness attacks per week
• if the request is for brand Keveyis or Ormalvi, the member has experienced therapeutic failure or intolerance to generic dichlorphenamide

Approval duration

initial: up to 2 months; reauthorization: up to 12 months