Pharmacy Prior Authorization Criteria

Lucemyra (lofexidine)

Indications for Prior Authorization

Lucemyra (lofexidine)

• For diagnosis of Opioid withdrawal
  Indicated for the mitigation of opioid withdrawal symptoms to facilitate abrupt opioid discontinuation in adults.

Criteria

Lucemyra

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 clonidine

P & T Revisions

2024-01-03, 2023-01-04, 2022-01-06, 2021-01-06, 2020-01-17

References

1. Lucemyra Prescribing Information. USWM, LLC. Louisville, KY. September 2020.

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Revision History

• 2024-01-03: Annual review: No updates required.
• 2023-01-04: Annual review: Updated criteria.
• 2022-01-06: Annual review: Updated criteria and background.
• 2021-01-06: Annual review: No updates required.
• 2020-01-17: Annual review: no updates required.

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