Indications for Prior Authorization
Chronic Refractory Gout
- Chronic Gout defined by patient having at least one of the following
- more than three gout flares in previous 18 months
- more than one tophus
- chronic gouty arthritis
All of the following must be met as a condition for coverage
- Must be prescribed by a Rheumatologist
- Patient must 18 years of age or older
- Patient has chart note documentation of therapeutic failure or contraindication to both allopurinol AND febuxostat (Uloric®) at therapeutic doses
This Medication is not approvable for the following condition(s).
Any condition not listed above as an approved indication.
Up to 8 mg IV every two weeks.
Duration of Therapy
Initial authorization: six months
Reauthorization: every six months based upon serum uric acid < 6mg/dl and patient has been compliant with every two week regimen.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: May 2011 Reviewed: December 2013