Pharmacy Prior Authorization Criteria

Xuriden (uridine triacetate)

Indications for Prior Authorization

Xuriden (uridine triacetate)

• For diagnosis of Hereditary orotic aciduria
  Indicated in adult and pediatric patients for the treatment of hereditary orotic aciduria.

Criteria

Xuriden

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of hereditary orotic aciduria [A]
AND
• Prescribed by or in consultation with a medical geneticist or other specialist that treats inborn errors of metabolism [B]

Xuriden

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy [C]

P & T Revisions

2024-07-01, 2023-10-04, 2023-06-16, 2022-06-14, 2021-08-03, 2020-07-14

References

1. Xuriden Prescribing Information. Wellstat Therapeutics Corporation, December 2019.
2. Balasubramaniam S, Duley JA, Christodoulou J. Inborn errors of pyrimidine metabolism: clinical update and therapy. J Inherit Metab Dis. 2014;37(5):687-98.
3. Jurecka A. Inborn errors of purine and pyrimidine metabolism. J Inherit Metab Dis. 2009;32(2):247-263.
4. Weinberg ME, Roman MC, Jacob P, et al. Enhanced uridine bioavailability following administration of a triacetyluridine-rich nutritional supplement. PloS one. 2011;6(2).

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Revision History

• 2024-07-01: Annual Review - No criteria changes
• 2023-10-04: Program update to standard reauthorization language. No changes to clinical intent
• 2023-06-16: Annual Review - no criteria changes
• 2022-06-14: Annual Review - no criteria changes
• 2021-08-03: 2021 Annual Review, no changes to criteria.
• 2020-07-14: 2020 Annual review. Removed reference to drug name in reauth criteria, no changes to clinical criteria.

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