Endari — Medical Mutual

Initial criteria

• Patient age ≥ 5 years; AND
• Endari is prescribed by, or in consultation with, a physician who specializes in SCD (e.g., a hematologist); AND
• Patient had an adequate trial of hydroxyurea unless the patient has a contraindication to hydroxyurea per the prescribing physician; AND
• History of trial of non-prescription L-glutamine supplementation; AND
• If brand Endari is being requested, patient has tried generic L-glutamine; AND Brand Endari is being requested due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the corresponding generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction.

Reauthorization criteria

• Provider attests to a positive response to therapy such as: decreased hospitalizations, decrease in sickle cell crisis, decrease in acute pain events, etc.

Approval duration

365 days (1 year) initial; 365 days (1 year) reauth