Pegloticase (Krystexxa®)

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

 

Last review date: December 2, 2013

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.