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


Initial approval 4 weeks

Renewal: One year (with documented effectiveness)

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: March 2013 Reviewed: December 2013