Vijoice (alpelisib) — Highmark
PIK3CA-related overgrowth spectrum (PROS) with severe manifestations
Preferred products
- Piqray 250 mg (alpelisib)
Initial criteria
- age ≥ 2 years
- Diagnosis of PIK3CA-related overgrowth spectrum (PROS) with severe manifestations
- If request is for Vijoice 250 mg, member has experienced therapeutic failure or intolerance to Piqray 250 mg
Reauthorization criteria
- Prescriber attests the member is tolerating therapy AND has experienced a therapeutic response defined as disease improvement OR delayed disease progression
Approval duration
12 months