Pegloticase (Krystexxa®)

Office administered

Indications for Prior Authorization

Chronic Refractory Gout

  • 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.

Duration of Therapy

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.

 


Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: May 2011 Reviewed: December 2013