Crofelemer (Fulyzaq®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Approvable for relief of non-infectious diarrhea

Patients must meet the following criteria for the indication(s) above:

  • Diagnosis of HIV or AIDS
  • Must be on antiretroviral therapy

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved uses not listed in the approved indications

Recommended Dosing:

  • 125 mg twice a day with food

Approval:

  • Initial approval 4 weeks
  • Renewal: One year (with documented effectiveness)

 

Last review date: December 2, 2013

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