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Prior Authorization Protocol
KEVEYISTM (dichlorphenamide)

NATL
Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    • For the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants
  2. Health Net Approved Indications and Usage Guidelines:
    • Diagnosis of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants

    AND 

    • Failure or clinically significant adverse effects to acetazolamide
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
    • Variants of periodic paralysis include paramyotonia congenita and Andersen syndrome.
    • Dichlorphenamide was originally FDA approved for the treatment of elevated intraocular pressure but was voluntarily withdrawn from the market by the manufacturer in 2002.
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose

    acetazolamide

    250 to 375 mg/day PO in divided doses

    375 mg/day

    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    Keveyis

    Initial dose of 50 mg PO BID; titrate based on individual response at weekly intervals up to a maximum recommended daily dose of 200 mg.

    Length of Benefit

  7. Product Availability:

    Tablet: 50 mg

  8. References:
    1. Keveyis [Prescribing Information]. Hawthorne, NY: Taro Pharmaceuticals U.S.A., Inc.; August 2015.
    2. Tawil R, McDermott MP, Brown R, et al. Randomized trials of dichlorphenamide in the periodic paralyses. Ann Neurol 2000;47:46-53.
    3. Clinical Pharmacology website. Available at: http://clinicalpharmacology-ip.com/. Accessed September 15, 2015.
    4. MicromedexR Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed September 15, 2015.
The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.