Daybue (trofinetide) — United Healthcare
Rett syndrome (RTT)
Initial criteria
- Diagnosis of Rett syndrome (RTT) confirmed by ONE of the following: (1) ALL of the following clinical signs and symptoms: (a) A pattern of development, regression, then recovery or stabilization AND (b) Partial or complete loss of purposeful hand skills such as grasping with fingers, reaching for things, or touching things on purpose AND (c) Partial or complete loss of spoken language AND (d) Repetitive hand movements, such as wringing the hands, washing, squeezing, clapping, or rubbing AND (e) Gait abnormalities, including walking on toes or with an unsteady, wide-based, stiff-legged gait OR (2) Confirmed genetic mutation in the MECP2 gene
- Prescribed by, or in consultation with, ONE of the following: (1) Geneticist OR (2) Pediatrician who specializes in childhood neurological or developmental disorders OR (3) Neurologist
- age ≥ 2 years
Reauthorization criteria
- Documentation of positive clinical response to Daybue therapy
Approval duration
12 months