ModifiedmhnPolicy CP.PHAR.115

KRYSTEXXA (PDF)

Defines medical necessity criteria, initial and continued authorization requirements, dosing limits, contraindications, co-administration requirements, approval durations by line of business, and coding guidance for pegloticase (Krystexxa) for commercial, HIM, and Medicaid lines of business.

Policy Summary

Payermhn

PolicyKRYSTEXXA (PDF)

Policy CodePolicy CP.PHAR.115

Change TypeMODIFIED

Effective DateJun 1, 2013

Next Review Date

Key ActionProvider must submit office chart notes, lab results, or other clinical information supporting that member has met all approval criteria

SourceLink

POLICY UPDATE CHANGES

Added combination use with methotrexate per labeling (co-administration requirement)

Prevention of concomitant use with pegadricase

Extended initial approval duration from 6 to 12 months for Medicaid and HIM

Added newly approved ready-to-use single-dose vial formulation

Removed losartan as a uricosuric agent from therapeutic alternatives

1FDA approved indication covered

18Required gout flare lookback months

8 mgMaximum dose per infusion