CurrentCignaPolicy N/A

Sickle Cell Disease - L-glutamine Prior Authorization Policy

Prior authorization policy for coverage of L-glutamine oral powder (Endari and generic) for treatment of sickle cell disease in Cigna-administered benefit plans, specifying criteria, documentation and duration of approval.

Policy Summary

PayerCigna

PolicySickle Cell Disease - L-glutamine Prior Authorization Policy

Policy CodePolicy N/A

Change TypeRevision; Annual reviews

Effective Date

Next Review Date

Key ActionPrior authorization is required for L-glutamine oral powder; approvals are provided for 1 year and documentation is required as noted in the criteria.

POLICY UPDATE CHANGES

Generic L-glutamine oral powder was added to the policy and policy name changed from 'Sickle Cell Disease - Endari PA' to 'Sickle Cell Disease - L-glutamine PA'.

Annual revisions on 01/03/2024 and 01/15/2025 noted 'No criteria changes.'

1Covered Indications

1 yrApproval Duration

>=5Min Age (yrs)

Coverage Summary

Coverage stance: covered_with_criteria. Scope: Prior authorization policy for coverage of L-glutamine oral powder (Endari and generic) for treatment of sickle cell disease in Cigna-administered benefit plans, specifying criteria, documentation and duration of approval. Approval duration: 1 year. Last review date: 01/15/2025.

Initial Therapy Criteria

FDA-Approved Indication

Approve for 1 year if the patient meets BOTH of the following (A and B):

ALL of the following

A: Patient is ≥ 5 years of age
B: The medication is prescribed by or in consultation with a physician who specializes in sickle cell disease (e.g., a hematologist)

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is recommended/required for prescription benefit coverage of L-glutamine oral powder; approvals are provided for 1 year.

Documentation Required

Documentation required

Documentation is required for use as noted in the criteria and may include chart notes, prescription claims records, prescription receipts, and/or other information.

Examples: chart notes, prescription claims records, prescription receipts, and/or other information.

Billing Rule

Prescriber specialty requirement

Medication must be prescribed by or in consultation with a physician who specializes in sickle cell disease (e.g., a hematologist).

Clinical Evidence & References

Prescribing information: Endari oral powder prescribing information, Emmaus Medical; October 2020.

Guideline citation: American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4:2656-2701.

Revision History

08/28/2024material_revision

Generic L-glutamine oral powder was added to the policy and policy name changed from 'Sickle Cell Disease - Endari PA' to 'Sickle Cell Disease - L-glutamine PA'.

01/03/2024annual_review

Annual revisions noted 'No criteria changes.'

01/15/2025annual_reviewLatest