Pharmacy Prior Authorization Criteria

Chenodal (chenodiol)

Indications for Prior Authorization

Chenodal (chenodiol)

• For diagnosis of Radiolucent Gallstones
  Indicated for patients with radiolucent stones in well-opacifying gallbladders, in whom selective surgery would be undertaken except for the presence of increased surgical risk due to systemic disease or age.

  The likelihood of successful dissolution is far greater if the stones are floatable or small. For patients with nonfloatable stones, dissolution is less likely and added weight should be given to the risk that more emergent surgery might result from a delay due to unsuccessful treatment. Safety of use beyond 24 months is not established. Chenodiol will not dissolve calcified (radiopaque) or radiolucent bile pigment stones.

Criteria

Chenodal

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of radiolucent gallstones
AND
• Patient has a well-opacifying gallbladder visualized by oral cholecystography
AND
• Trial and failure, contraindication or intolerance to ursodiol
AND
• Patient is not a candidate for surgery
AND
• Stones are not calcified (radiopaque) or radiolucent bile pigment stones
AND
• Prescribed by or in consultation with one of the following:
• Gastroenterologist
• A provider who has specialized expertise in the management of gallstones

Chenodal

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient’s disease status has been re-evaluated since the last authorization to confirm the patient’s condition warrants continued treatment as evidenced by oral cholecystograms or ultrasonograms
AND
• Prescribed by or in consultation with one of the following:
• Gastroenterologist
• A provider who has specialized expertise in the management of gallstones

P & T Revisions

2024-03-21, 2023-03-16, 2022-03-18, 2021-02-04, 2020-03-04

References

1. Chenodal Prescribing Information. Travere Therapeutics. San Diego, CA. July 2023.

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Revision History

• 2024-03-21: 2024 annual review - no criteria changes.
• 2023-03-16: Annual review: no criteria changes.
• 2022-03-18: Annual review: updated diagnosis criterion to specify it's for "gallstones" and added specialist requirement for initial and reauthorization.
• 2021-02-04: Annual review
• 2020-03-04: New PA criteria

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