Pharmacy Prior Authorization Criteria

Pancreatic Enzyme Products

Indications for Prior Authorization

Pancreaze (pancrelipase), Pertzye (pancrelipase)

• For diagnosis of Exocrine Pancreatic Insufficiency
  Indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients.

Viokace (pancrelipase)

• For diagnosis of Exocrine Pancreatic Insufficiency
  In combination with a proton pump inhibitor, is indicated for the treatment of exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy in adults.

Criteria

Pancreaze, Pertzye, Viokace

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 BOTH of the following:
• Creon (pancrelipase) delayed-release capsules
• Zenpep (pancrelipase) delayed-release capsules

P & T Revisions

2024-09-26, 2023-09-22, 2022-11-02, 2021-09-22, 2021-07-07, 2020-09-09, 2019-09-16

References

1. Pancreaze Prescribing Information. Vivus, Inc. Campbell, CA. February 2024.
2. Pertzye Prescribing Information. Digestive Care, Inc.; Bethlehem, PA. February 2024.
3. Viokace Prescribing Information. Allergan USA, Inc.; Irvine, CA. February 2024.
4. Creon Prescribing Information. AbbVie Inc.; North Chicago, IL. February 2024
5. Zenpep Prescribing Information. Allergan USA, Inc.; Irvine, CA. February 2024.

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Revision History

• 2024-09-26: 2024 UM Annual Review. No changes. Background updates
• 2023-09-22: 2023 UM Annual Review. No criteria changes. Cleaned up GPIs and updated references
• 2022-11-02: 2022 Annual Review
• 2021-09-22: 2021 UM Annual Review.
• 2021-07-07: AutoUpdate- Added New ST edits for Pancreaze 2600 units & 37,000 unit strength eff 9/1/2021
• 2020-09-09: 2020 UM Annual Review.
• 2019-09-16: 2019 Annual Review

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