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Krystexxa Medicare Part B – Prior Authorization

Policy

Last Review: 01/01/2023
Part B Prior Authorization Criteria for Approval

Krystexxa will be approved when ALL of the following are met:

    1. The requested medication is being used for ONE of the following:

        A. An FDA approved indication

OR

        B. An indication in CMS approved compendia

AND

    2. The patient does NOT have any FDA labeled contraindications to the requested medication

AND

    3. The requested quantity (dose) is within FDA labeled dosing or supported in compendia for the requested indication

 

Length of Approval: up to 12 months

 

Notes:

  • Length of approval may be shorter due to provider network participation status.
  • LCD/NCD criteria review completed, if applicable, in addition to the Plan’s Medicare Part B criteria.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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