Pharmacy Prior Authorization Criteria

Soaanz (torsemide)

Indications for Prior Authorization

Soaanz (torsemide)

• For diagnosis of Edema
  Indicated in adults for the treatment of edema associated with heart failure or renal disease.

Criteria

Soaanz

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of one of the following:
• Heart failure
• Renal disease
AND
• Used for the treatment of edema
AND
• Trial and failure or intolerance to generic torsemide
AND
• Trial and failure or intolerance to ONE of the following generics:
• bumetanide
• furosemide

Soaanz

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., maintaining euvolemia)

P & T Revisions

2024-05-20, 2023-11-30, 2023-05-03, 2022-05-04

References

1. Soaanz Prescribing Information. Sarfez Pharmaceuticals, Inc. Vienna, VA. December 2021.

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Revision History

• 2024-05-20: 2024 annual review. No change to clinical content.
• 2023-11-30: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-05-03: Annual review - no changes.
• 2022-05-04: New UM Program

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