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
125 mg twice a day with food
Initial approval 4 weeks
Renewal: One year (with documented effectiveness)
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: March 2013 Reviewed: December 2013