KRYSTEXXA (pegloticase)

KRYSTEXXA (pegloticase)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• Chronic Gout defined by patient having at least one of the following
  • More than three gout flares in previous 18 months
  • More than one tophus
  • Chronic gouty arthritis

All of the following must be met as a condition for coverage:

• Must be prescribed by a Rheumatologist
• Patient must 18 years of age or older
• Patient has chart note documentation of therapeutic failure or contraindication to both allopurinol AND febuxostat (Uloric®) at therapeutic doses

This Medication is not approvable for the following condition(s):

• Any condition not listed above as an approved indication

Dosing:

• Up to 8 mg IV every two weeks

Approval:

• Initial authorization: six months
• Reauthorization: every six months based upon serum uric acid < 6mg/dl and patient has been compliant with every two week regimen