Duvyzat — Medical Mutual

Initial criteria

• Patient is age ≥ 6 years; AND
• Diagnosis of Duchenne Muscular Dystrophy confirmed by genetic testing with a confirmed pathogenic variant in the dystrophin gene; AND
• Patient has completed baseline function tests (e.g., time to wheelchair assistance, required respiratory assistance/pulmonary function tests, four-stair climb [4SC], 6-minute walk test [6MWT], time to walk/run 10 meters [10MWT], or North Star Ambulatory Assessment [NSAA]); AND
• Patient is ambulatory; AND
• Patient has been stable on a systemic corticosteroid therapy for at least 6 months; AND
• Medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne Muscular Dystrophy (DMD) and/or neuromuscular disorders; AND
• Prescribing physician has obtained and evaluated baseline platelet counts and triglycerides levels prior to initiation

Reauthorization criteria

• Patient has been established on the medication for at least 1 year; AND
• Patient is age ≥ 6 years; AND
• Patient is ambulatory; AND
• Patient continues to be stable on a systemic corticosteroid therapy; AND
• Medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne Muscular Dystrophy (DMD) and/or neuromuscular disorders; AND
• According to the prescriber, patient continues to benefit from therapy, as demonstrated by a stabilization or slowed decline on timed function tests (e.g., 4-stair climb, 6-minute walk test, time-to-rise) or in the North Star Ambulatory Assessment (NSAA) score

Approval duration

1 year initial, 1 year reauth