FULYZAQ (crofelemer)

FULYZAQ (crofelemer)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

• Approvable for relief of non-infectious diarrhea

Patients must meet the following criteria for the indication(s) above:

• Diagnosis of HIV or AIDS
• Must be on antiretroviral therapy

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

• All non-FDA approved uses not listed in the approved indications

Recommended Dosing:

• 125 mg twice a day with food

Approval:

• Initial approval 4 weeks
• Renewal: One year (with documented effectiveness)