Chenodal (chenodiol) — CareFirst (Caremark)
Radiolucent stones in well-opacifying gallbladders in members with increased surgical risk due to systemic disease or age
Preferred products
- ursodiol
Initial criteria
- Member has an increased surgical risk due to systemic disease or age
- Member experienced an inadequate treatment response or intolerance to ursodiol
- Member will not exceed a dose of 16 mg/kg/day and current weight must be provided
Reauthorization criteria
- Member has experienced partial or complete dissolution of stones OR provider will discontinue therapy if no response by 18 months of treatment
- Member has not experienced signs and symptoms of hepatotoxicity (e.g., abdominal pain, bruising, dark-colored urine, jaundice)
- Member will not exceed a dose of 16 mg/kg/day and current weight must be provided
- Cumulative use with Chenodal will not exceed 24 months
Approval duration
12 months