Vijoice (alpelisib) — United Healthcare
PIK3CA-Related Overgrowth Spectrum (PROS)
Initial criteria
- Diagnosis of PIK3CA-Related Overgrowth Spectrum (PROS)
- AND patient is 2 years of age or older
- AND patient has severe manifestations of PROS requiring systemic therapy
Reauthorization criteria
- Documentation of positive clinical response to Vijoice therapy
Approval duration
12 months