CurrentNeighborhood Health Plan of Rhode IslandPolicy 3369-C

Sucraid (sacrosidase) — prior authorization and quantity limits

Defines coverage, prior authorization, and quantity limits for Sucraid (sacrosidase) oral solution for treatment of congenital sucrase-isomaltase deficiency; applies to prescribers, pharmacies, and members covered by Neighborhood Health Plan of Rhode Island using CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySucraid (sacrosidase) — prior authorization and quantity limits

Policy CodePolicy 3369-C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain initial prior authorization and provide documentation confirming diagnosis (small bowel biopsy, genetic testing, or sucrose hydrogen breath test).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial PAAuthorization type

12 monthsDuration of approval

25 daysBottle limit (354 mL)

21 daysSingle-use limit (300 mL)

Coverage Criteria for Sucraid (sacrosidase)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial coverage criteria

Covered when ALL of the following are met:

Primary diagnosis: Patient has a diagnosis of congenital sucrase-isomaltase deficiency.

Referenced in coverage criteria

Diagnostic confirmation: Diagnosis is confirmed by at least one of the following: small bowel biopsy, genetic testing, or sucrose hydrogen breath test.

Policy lists three acceptable confirmation methods

Requests for Sucraid (sacrosidase) without a diagnosis of congenital sucrase‑isomaltase deficiency (CSID) are not authorized. Coverage is provided only when the patient has a documented diagnosis of CSID and all other policy requirements are met.

Use of Sucraid for indications other than genetically determined sucrase deficiency (CSID) is not covered under this policy. Requests for non‑CSID indications do not meet the coverage criteria and will be denied.

Drug Product References and Quantity Limits

Drug product referencesNDC

NDC not listed

Policy lists product formulations but does not provide NDCs.

Quantity limits (bottle)

Multiple-dose bottle limits354 mL = 25 days per 30-day fill; 1062 mL = 75 days per 90-day fill

Bottle volume detailEach multiple-dose bottle contains 4 oz (118 mL) total

Refill processing noteDurations (25 days / 75 days) allow time for refill processing within the 30- and 90-day fill periods

Quantity limits (single-use)

Single-use container limits300 mL = 21 days per month; 900 mL = 63 days per 3 months

Single-use pack detailEach carton contains 150 single-use containers of 2 mL each (300 mL total)

Refill processing noteDurations (21 days / 63 days) allow time for refill processing within the 25- and 75-day fill periods

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Initial prior authorization is required for Sucraid (sacrosidase). Coverage is granted when the patient has a diagnosis of congenital sucrase-isomaltase deficiency and the documentation and quantity-limit criteria below are met.

Quantity limits apply

Note

Documentation Required

Required diagnosis confirmation

Documentation supporting the diagnosis must be provided. Acceptable confirmation methods include small bowel biopsy, genetic testing, or a sucrose hydrogen breath test.

Denial Risk

Provider action

Request may be denied if the patient does not have a diagnosis of congenital sucrase-isomaltase deficiency or if required diagnostic confirmation and documentation are not provided.

Definitions and Diagnostic Methods

Sucraid (sacrosidase) Oral Solution

DrugSucraid (sacrosidase) Oral Solution — an oral enzyme replacement therapy indicated as replacement therapy for genetically determined sucrase deficiency (part of congenital sucrase-isomaltase deficiency)

FormulationOral solution formulation intended to replace sucrase activity in patients with CSID

Indication scopeUse is specific to genetically determined sucrase deficiency within congenital sucrase-isomaltase deficiency (CSID)

Diagnosis confirmation methods

Acceptable confirmation methodsSmall bowel biopsy confirming CSID

Acceptable confirmation methodsGenetic testing confirming CSID

Acceptable confirmation methodsSucrose hydrogen breath test confirming CSID

Background on Congenital Sucrase-Isomaltase Deficiency

Congenital sucrase‑isomaltase deficiency (CSID) is a genetically determined inability to digest sucrose and some starch components due to deficient sucrase‑isomaltase activity. Sucraid (sacrosidase) oral solution is an enzyme replacement therapy intended to replace sucrase activity in patients with genetically determined sucrase deficiency; authorization for Sucraid is contingent on a confirmed diagnosis of CSID per the policy requirements.