Pegloticase (Krystexxa®)


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


  • Up to 8 mg IV every two weeks


  • 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


Last review date: December 2, 2013

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