Pharmacy Prior Authorization Criteria

Antigout Agents

For diagnosis of Gout
A xanthine oxidase (XO) inhibitor indicated for the chronic management of hyperuricemia in adult patients with gout who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable.
Uloric is not recommended for the treatment of asymptomatic hyperuricemia.

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to allopurinol

2024-07-09, 2023-08-02, 2022-08-03, 2021-10-04, 2021-09-27, 2021-05-18, 2020-12-14, 2020-09-04, 2019-12-10, 2019-09-03

Uloric Prescribing Information. Takeda Pharmaceuticals America, Inc. Deerfield, IL. April 2023.

2024-07-09: 2024 Annual Review. Added in trial duration as per Comprehensive UM Grid.
2023-08-02: Annual review, no changes to criteria
2022-08-03: Annual Review, added FDA approved dx requirement to criteria.
2021-10-04: Annual Review
2021-09-27: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
2021-05-18: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
2020-12-14: Updated target to include generic febuxostat, brand Uloric is excluded so was removed as a target
2020-09-04: Annual review no changes
2019-12-10: Added Zurampic as a target.
2019-09-03: Annual review - updated reference no changes to clinical criteria