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)
Last review date: December 2, 2013