Payer PolicyActive
Givosiran (Givlaari)
EVICORE-MEDICAL_DRUG-9FA7A35B
EviCore by Evernorth
Effective: May 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Givosiran (Givlaari) is covered for the treatment of adults (≥18 years) with an FDA‑approved diagnosis of acute hepatic porphyria (AHP) and is not covered for patients under 18 or for non‑FDA‑approved indications. Approval requires prescription by or consultation with a gastroenterologist, hepatologist, or AHP specialist, documentation of diagnosis and age, adherence to applicable safety criteria, and the recommended dosing of 2.5 mg/kg subcutaneously once monthly.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of adults with acute hepatic porphyria (AHP)."
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