Dartisla ODT (glycopyrrolate) — Highmark

Preferred products

• generic glycopyrrolate 2 mg tablets

Initial criteria

• age ≥ 18 years
• diagnosis of peptic ulcer disease (ICD-10: K27)
• will be using Dartisla ODT as an adjunct to treatment of peptic ulcer disease (e.g., PPI or H2RA therapy)
• experienced therapeutic failure or intolerance to plan-preferred generic glycopyrrolate 2 mg tablets

Reauthorization criteria

• meets one of the following: recurrence of peptic ulcer disease (ICD-10: K27) OR peptic ulcer disease has not resolved
• will be using Dartisla ODT as an adjunct to treatment of peptic ulcer disease (e.g., PPI or H2RA therapy)
• prescriber attests to positive clinical response to previous treatment with Dartisla ODT

Approval duration

3 months