CurrentUnitedHealthcarePolicy N/A

dichlorphenamide (Keveyis, Ormalvi) prior authorization

Prior authorization and reauthorization requirements for dichlorphenamide products (Keveyis, Ormalvi, generic) for treatment of primary hyperkalemic and hypokalemic periodic paralysis and related variants; applies to UnitedHealthcare pharmacy benefit members.

Policy Summary

PayerUnitedHealthcare

Policydichlorphenamide (Keveyis, Ormalvi) prior authorization

Policy CodePolicy N/A

Change TypeMaterial updates to covered products and authorization duration

Effective DateMay 1, 2025

Next Review DateFeb 1, 2025

Key ActionSubmit prior authorization documentation showing diagnosis of primary hyperkalemic or hypokalemic periodic paralysis for initial approval (authorization issued for 12 months).

SourceLink

POLICY UPDATE CHANGES

Updated initial authorization duration to 12 months.

Added generic dichlorphenamide and Ormalvi to the policy.

Added coverage exclusion statement for brand Keveyis and Ormalvi (typically excluded; tried/failed criteria may apply).

12 monthsinitial and reauthorization approval period

Keveyis, Ormalvi, genericproducts referenced

hyperkalemic & hypokalemicindications listed

Prior Auth/Notification

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Coverage Criteria for Dichlorphenamide Products

inv-01: Initial Therapy — Covered when ONE of the following is met:

Covered when ONE of the following is met:

Diagnosis of primary hyperkalemic periodic paralysis or related variant

Initial approval for 12 months

Diagnosis of primary hypokalemic periodic paralysis or related variant

Initial approval for 12 months

inv-02: Reauthorization — Covered when the following is met:

Covered when the following is met:

Clinical response: Documentation of positive clinical response

Reauthorization issued for 12 months

Note: Brand products Keveyis and Ormalvi are typically excluded from coverage. Plans may apply tried/failed or other exclusion rules specific to the member’s benefit; providers should consult the member’s plan-specific edits to determine whether an exception or step-therapy requirement applies.

Initial Therapy Criteria

inv-11: Initial Therapy — detailed initial approval criteria (use nested nodes as source).

Initial approval criteria

Diagnosis options: Diagnosis of primary hyperkalemic periodic paralysis or primary hypokalemic periodic paralysis or related variants

Authorize for 12 months

Reauthorization / Continuation Criteria

inv-12: Reauthorization — continuation rules and required documentation for ongoing approval.

Reauthorization rules

Positive response: Documentation of positive clinical response

Authorize for 12 months

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization required for initial therapy. Approvals for dichlorphenamide, Keveyis (brand), or Ormalvi will be issued only when documentation supports one of the covered diagnoses: a diagnosis of primary hyperkalemic periodic paralysis (or related variant) OR a diagnosis of primary hypokalemic periodic paralysis (or related variant). Authorization for initial approvals will be issued for 12 months.

Affected products: dichlorphenamide, Keveyis (brand), Ormalvi

Documentation Required

Reauthorization — Documentation Required

Authorization will be issued for 12 months. For reauthorization, documentation of a positive clinical response is required to continue therapy; reauthorization approvals will also be issued for 12 months.

Reauthorization requirement: documentation of positive clinical response
Authorization period: 12 months

Step Therapy and Product-Specific Edits

Product / Edit	Plan note
Keveyis (brand)	Typically excluded from coverage; may require tried/failed criteria per plan — refer to plan-specific step edits and exclusions.
Ormalvi (brand)	Typically excluded from coverage; may require tried/failed criteria per plan — refer to plan-specific step edits and exclusions.
Generic dichlorphenamide	Covered with prior authorization when coverage criteria are met; plan-specific step edits may still apply.
Plan-specific step edits	Exclusion or tried/failed requirements for brand products may be implemented at the plan level — check member benefit plan for exact step therapy rules.

Background

Dichlorphenamide is an oral carbonic anhydrase inhibitor indicated for treatment of primary hyperkalemic periodic paralysis and primary hypokalemic periodic paralysis (and related variants). Both Keveyis and Ormalvi are referenced as brand products for these indications; approval and use should follow the policy’s coverage criteria and plan requirements.

Key Definitions

Definitions — periodic paralysis disorders and related terminology

Disorders definedPrimary hyperkalemic periodic paralysis and primary hypokalemic periodic paralysis are periodic paralysis disorders characterized by episodes of muscle weakness associated with potassium dysregulation.

Drug classDichlorphenamide (Keveyis, Ormalvi) is an oral carbonic anhydrase inhibitor used to treat these disorders.

Indicated variantsPolicy and product labeling include related variants of primary hyperkalemic and hypokalemic periodic paralysis.

Coverage requirementMembers must meet the policy coverage criteria (diagnosis of primary hyperkalemic or hypokalemic periodic paralysis or related variant) for authorization.

Authorization durationWhen authorized, therapy is issued for a 12-month approval period.