Pharmacy Prior Authorization Criteria

Endari (L-glutamine oral powder)

Indications for Prior Authorization

Endari (L-glutamine)

• For diagnosis of Sickle Cell Disease
  Indicated to reduce the acute complications of sickle cell disease in adult and pediatric patients 5 years of age and older.

Criteria

Brand Endari, Generic l-glutamine

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of sickle cell disease
AND
• Used to reduce acute complications of sickle cell disease
AND
• Patient is 5 years of age and older

Brand Endari, Generic l-glutamine

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-08-02, 2024-07-03, 2023-09-29, 2023-07-20, 2022-07-08, 2022-05-04, 2021-07-07, 2020-12-24, 2020-06-25

References

1. Endari Prescribing Information. Emmaus Medical, Inc. Torrance, CA. October 2020.

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Revision History

• 2024-08-02: Added generic l-glutamine to guideline to match brand Endari criteria
• 2024-07-03: 2024 Annual Review. No criteria changes.
• 2023-09-29: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-07-20: Annual review
• 2022-07-08: 2022 Annual Review- no changes
• 2022-05-04: Removed requirement for 2 or more painful sickle cell crises within the past months and the specialist requirement. Added age criterion per PI.
• 2021-07-07: Annual Review
• 2020-12-24: Update Endari criteria to align with CMS Stage 5/6 review concern.
• 2020-06-25: Annual Review.

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