Payer PolicyActive
Givosiran (Givlarri)
EVICORE-MEDICAL_DRUG-CE1539DB
EviCore by Evernorth
Effective: March 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered for the FDA‑approved treatment of adults (≥18) with acute hepatic porphyria; pediatric (<18) and off‑label uses are excluded. Approval requires documented clinical AHP features plus elevated urinary ALA or PBG, a porphyria attack in the past 6 months requiring hospitalization/urgent visit or IV hemin, and prescription by or in consultation with a gastroenterologist, hepatologist, or AHP specialist (with supporting documentation).
Coverage Criteria Preview
Key requirements from the full policy
"Givlaari is indicated for the treatment of adults with acute hepatic porphyria (AHP)."
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