FLEQSUVY BACLOFEN Oral Instructions
- June 3, 2024
- FLEQSUVY
Table of Contents
BACLOFEN Oral
Instructions STANDARD COMMERCIAL DRUG FORMULARY
PRIOR AUTHORIZATION GUIDELINES
BACLOFEN Oral
BACLOFEN
Generic| Brand| HICL| GCN| Medi-Span|
Exception/Other
---|---|---|---|---|---
BACLOFEN| OZOBAX. BACLOFEN| | 64209| GPI-14
(75100010002070)|
BACLOFEN| FLEQSUVY| | 51885| GPI-14
(75100010001825)|
BACLOFEN| LYVISPAH| | 51638
51639
51652| GPI-14
(75100010003010),
(75100010003020),
(75100010003030)|
GUIDELINES FOR USE
-
Is the request for Ozobax and the patient meets ALL of the following criteria?
• The patient had a trial of or contraindication to generic baclofen tablets
• The patient is unable to swallow generic baclofen tablets
If yes, approve for 6 months by GPID or GPI-14 with a quantity limit of #80mL per day.
If no, continue to #2. -
Is the request for Fleqsuvy and the patient meets ALL of the following criteria?
• The patient had a trial of or contraindication to generic baclofen tablets
• The patient is unable to swallow generic baclofen tablets
If yes, approve for 12 months by GPID or GPI-14 with a quantity limit of #16mL per day.
If no, continue to #3. -
Is the request for Lyvispah and the patient meets ALL of the following criteria?
• The patient had a trial of or contraindication to generic baclofen tablets
• The patient is unable to swallow generic baclofen tablets
If yes, approve for 12 months by GPID or GPI-14 for all strengths with the following quantity limits:
- 5mg: #9 per day.
- 10mg: #3 per day.
- 20mg: #4 per day.
If no, do not approve.
DENIAL TEXT: See the denial text at the end of the guideline.
*Some terms are already pre-defined in parenthesis. Please use these definitions if the particular text you need to use does not already have a definition(s) in it.
Our guideline named BACLOFEN (Ozobax, Fleqsuvy, Lyvispah) requires the
following rule(s) to be met for approval:
A. You have tried or have a contraindication (harmful for) to generic baclofen
tablets
B. You are unable to swallow generic baclofen tablets
Your doctor told us [INSERT PT SPECIFIC INFO PROVIDED]. We do not have
information showing you [INSERT UNMET CRITERIA]. This is why your request is
denied. Please work with your doctor to use a different medication or get us
more information if it will allow us to approve this request.
RATIONALE
For further information, please refer to the Prescribing Information and/or
Drug Monograph for Ozobax Fleqsuvy, and Lyvispah.
REFERENCES
- Ozobax [Prescribing Information]. Athens, GA: Metacel Pharmaceuticals, LLC; May 2020.
- Fleqsuvy [Prescribing Information]. Wilmington, MA: Azurity Pharmaceuticals, Inc.; February 2022.
- Lyvispah [Prescribing Information]. Roswell, GA: Saol Therapeutics, Inc.; November 2021.
| Library | Commercial | NSA |
|---|---|---|
| Yes | Yes | NO |
Part D Effective: N/A
Commercial Effective: 10/01/22
Created: 11/19
Client Approval: 09/22
P &T Approval: 07/22
Copyright © 2022 MedImpact Healthcare Systems, Inc. All rights reserved.
This document is proprietary to MedImpact.
MedImpact maintains the sole and exclusive ownership, right, title, and
interest in and to this document.
Revised: 9/1/2022
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