Pharmacy Prior Authorization Criteria

Piasky (crovalimab)

Indications for Prior Authorization

Piasky (crovalimab)

• For diagnosis of Paroxysmal nocturnal hemoglobinuria (PNH)
  Indicated for the treatment of adult and pediatric patients 13 years and older with paroxysmal nocturnal hemoglobinuria (PNH) and body weight of at least 40 kg.

Criteria

Piasky

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH)
AND
• Patient is 13 years of age or older
AND
• Patient weighs at least 40 kg
AND
• Trial and failure, contraindication, or intolerance to one of the following:
• Soliris (eculizumab)
• Ultomiris (ravulizumab)
AND
• Prescribed by or in consultation with a hematologist/oncologist

Piasky

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., hemoglobin stabilization, decrease in the number of red blood cell transfusions)
AND
• Trial and failure, contraindication, or intolerance to one of the following:
• Soliris (eculizumab)
• Ultomiris (ravulizumab)

P & T Revisions

2024-10-11, 2024-09-03, 2024-09-03, 2024-09-03

References

1. Piasky Prescribing Information. Genentech, Inc. San Francisco, CA. June 2024.

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Revision History

• 2024-10-11: Removal of step through Empaveli or Fabhalta
• 2024-09-03: New Program for Piasky
• 2024-09-03: New Program for Piasky
• 2024-09-03: New Program for Piasky

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