Vykat XR (diazoxide choline) — Highmark
Hyperphagia due to Prader-Willi syndrome (PWS)
Initial criteria
- age ≥ 4 years
- Diagnosis of Prader-Willi syndrome (ICD-10: Q87.11) confirmed by documentation of genetic analysis with identification of abnormal DNA methylation of chromosome 15q11.2-q13
- Member is experiencing hyperphagia due to the PWS diagnosis
Reauthorization criteria
- Prescriber attests that the member has experienced a decrease in hyperphagic and food-related behaviors
Approval duration
12 months