Endari — Medica
sickle cell disease
Preferred products
- generic l-glutamine oral powder
Initial criteria
- Patient meets the standard Sickle Cell Disease – L-glutamine Prior Authorization Policy criteria
- Patient has tried generic l-glutamine oral powder [documentation required]
- Patient cannot continue to use the generic l-glutamine oral powder due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) between the brand and bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
1 year