L-glutamine Powder for Solution — United Healthcare

Initial criteria

• Diagnosis of sickle cell disease
• Used to reduce acute complications of sickle cell disease
• Patient is using Endari with concurrent hydroxyurea therapy OR Patient is unable to take hydroxyurea due to a contraindication or intolerance
• Patient has had 2 or more painful sickle cell crises within the past 12 months
• History of failure to non-prescription L-glutamine supplementation

Reauthorization criteria

• Documentation of positive clinical response to Endari therapy

Approval duration

12 months