nitisinone

Drug - nitisinone (Orfadin®, Nityr®)

November 2018

Therapeutic area - Hereditary tyosinemia type 1

Approval criteria

• Patient has a diagnosis of hereditary tyrosinemia type 1 AND
• Prescriber provides documentation showing that the patient or the patient’s caregiver has been counseled on the need to maintain dietary restriction of tyrosine and phenylalanine

Quantity limit

• 2mg/kg/day
• Patient’s weight must be supplied at time of request and for any renewals and dosage increases

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411