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

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.

Press Esc to cancel

El sitio Web al que está siendo transferido no es provisto por WHA. Las Condiciones de Uso y las Prácticas de Privacidad en Internet de WHA no se aplican a este sitio Web asociado que usted está usando. Revise las políticas sobre la privacidad y condiciones de uso de este sitio Web asociado. WHA no tiene control sobre la exactitud, la totalidad o la actualidad del contenido del sitio Web asociado. WHA no puede garantizar que los servicios de traducción de idiomas estarán disponibles en el sitio vinculado.

Presione «Esc» para cancelar