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)
- 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)
Piasky
Non Formulary
Length of Approval: 12 Month(s)
- Submission of medical records (e.g., chart notes) confirming a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) AND
- Patient is 13 years of age or older AND
- Patient weighs at least 40 kg AND
- Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to one of the following:
- Soliris (eculizumab)
- Ultomiris (ravulizumab)
- Prescribed by or in consultation with a hematologist/oncologist
P & T Revisions
2025-02-05, 2024-10-11, 2024-09-03, 2024-09-03, 2024-09-03
References
- Piasky Prescribing Information. Genentech, Inc. San Francisco, CA. June 2024.
Revision History
- 2025-02-05: Addition of NF criteria to guideline
- 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
HEALTHY LIVING