Ryplazim® (plasminogen, human-tvmh)

Ryplazim is covered only for the FDA‑approved indication of plasminogen deficiency type 1 and is excluded for all other uses. Coverage requires confirmed biallelic PLG mutations, a pre‑treatment plasminogen activity ≤45% with compatible lesion history, hematologist prescribing/consultation, initial approval for 3 months (renewal for 12 months) with documented clinical benefit or a ≥10% absolute increase in trough plasminogen activity versus baseline, and submission of genetic test results, baseline/trough plasminogen levels, clinical progress notes, hematology documentation, and dosing records (6.6 mg/kg IV every 2–4 days).

"Treatment of patients with plasminogen deficiency type 1 (hypoplasminogenemia) (FDA‑approved indication)."

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