Prader-Willi Syndrome - Vykat XR Prior Authorization Policy
Prior authorization policy for coverage of Vykat XR for treatment of hyperphagia in patients with Prader-Willi syndrome under Cigna-administered health benefit plans; specifies clinical criteria, prescriber requirements, approval duration, and non-covered uses.
No material clinical or coverage changes in this revision.
Coverage Criteria for Vykat XR
FDA-Approved Indication
Vykat XR is covered as medically necessary for treatment of hyperphagia in patients with Prader-Willi syndrome when ALL of the following criteria are met:
Initial approval criteria
- Patient is ≥ 4 years of age;≥ 4 years
- Diagnosis of Prader-Willi syndrome established by identification of abnormal DNA methylation of chromosome 15q11.2-q13;
- Patient has hyperphagia;
- Medication prescribed by or in consultation with an endocrinologist.
Because of specialized skills required for evaluation and monitoring, approval requires prescription by or consultation with a physician who specializes in the condition being treated.
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