Voydeya (danicopan) — United Healthcare

paroxysmal nocturnal hemoglobinuria (PNH)

Initial criteria

Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH)
AND Patient is currently receiving complement protein C5 inhibitor eculizumab or Ultomiris (ravulizumab)
AND Patient is experiencing extravascular hemolysis (EVH) while on complement protein C5 inhibitor eculizumab or Ultomiris (ravulizumab)
AND Patient will continue to receive complement protein C5 inhibitor eculizumab or Ultomiris (ravulizumab)
AND Patient is not receiving Voydeya in combination with a complement protein C3 inhibitor [e.g., Empaveli (Pegcetacoplan)] or a complement factor B inhibitor [e.g., Fabhalta (iptacopan)] used for the treatment of PNH

Documentation of positive clinical response to Voydeya therapy [e.g., decrease in extravascular hemolysis (EVH), increased or stabilization of hemoglobin levels, reduction in transfusions, improvement in hemolysis, etc.]
AND Patient continues to receive Voydeya in combination with complement protein C5 inhibitor eculizumab or Ultomiris (ravulizumab) for PNH
AND Patient is not receiving Voydeya in combination with a complement protein C3 inhibitor [e.g., Empaveli (Pegcetacoplan)] or a complement factor B inhibitor [e.g., Fabhalta (iptacopan)] used for the treatment of PNH

12 months