Kuvan (sapropterin dihydrochloride) — United Healthcare
phenylketonuria (PKU)
Initial criteria
- Diagnosis of phenylketonuria (PKU)
- AND Patient is actively on a Phe-restricted diet
- AND Patient is not receiving the requested medication in combination with Palynziq (pegvaliase-pqpz)
Reauthorization criteria
- Patient is actively on a Phe-restricted diet
- AND Blood Phe levels continue to remain lower than baseline level
- AND Patient is not receiving the requested medication in combination with Palynziq (pegvaliase-pqpz)
Approval duration
12 months