Pharmacy Prior Authorization Criteria

Voydeya (danicopan)

Indications for Prior Authorization

Voydeya (danicopan)

• For diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH)
  Indicated as add-on therapy to ravulizumab or eculizumab for the treatment of extravascular hemolysis (EVH) in adults with paroxysmal nocturnal hemoglobinuria (PNH).

  Limitations of Use: Voydeya has not been shown to be effective as monotherapy and should only be prescribed as an add-on to ravulizumab or eculizumab.

Criteria

Voydeya

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH)
AND
• Will be used as add-on therapy to Ultomiris (ravulizumab) or Soliris (eculizumab)
AND
• Hemoglobin levels less than or equal to 9.5 g/dL
AND
• Absolute reticulocyte count greater than or equal to 120 × 10^9 /L
AND
• Prescribed by or in consultation with a hematologist/oncologist

Voydeya

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
• Will be used as add-on therapy to Ultomiris (ravulizumab) or Soliris (eculizumab)

P & T Revisions

2024-06-05, 2024-05-01

References

1. Voydeya Prescribing Information. Alexion Pharmaceuticals, Inc. Boston, MA. March 2024.

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Revision History

• 2024-06-05: Removed trial requirements
• 2024-05-01: New Program for Voydeya

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