CurrentCignaPolicy N/A

Bylvay (odevixibat) prior authorization

Defines Cigna's prior authorization requirements and medical necessity criteria for coverage of Bylvay (odevixibat) for progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (ALGS). Applies to prescription benefit plans administered by Cigna companies.

Policy Summary

PayerCigna

PolicyBylvay (odevixibat) prior authorization

Policy CodePolicy N/A

Change TypeAdded ALGS criteriarevised prior therapy examples

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of age, genetic confirmation of PFIC or ALGS, serum bile acids above lab ULN, trials of ≥2 systemic medications (unless contraindicated), and absence of cirrhosis or hepatic decompensation.

SourceLink

POLICY UPDATE CHANGES

Alagille Syndrome: This condition and criteria for approval was added to the policy.

Fenofibrate was added to the Note with examples of systemic medications that should be tried prior to approval of Bylvay for both Alagille Syndrome and PFIC.

2FDA‑approved indications covered (PFIC, ALGS)

6 moInitial approval duration

1 yrRenewal duration for responders

≥3 mo / ≥12 moMinimum ages (PFIC / ALGS)

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