Drizalma Sprinkle (duloxetine) — Highmark

Initial criteria

• age ≥ 18 years
• documented diagnosis of fibromyalgia (ICD-10: M79.7)
• clinical documentation of fibromyalgia diagnosis including all of the following: widespread bilateral pain above and below the waist; pain ≥ 3 months duration; at least one fibromyalgia-related symptom such as cognitive impairment, fatigue, sleep disturbance, neurological symptoms, or exercise intolerance
• inability to swallow capsules/tablets

Reauthorization criteria

• prescriber attests member has experienced positive clinical response to therapy
• prescriber attests member continues to have an inability to swallow capsules/tablets

Approval duration

12 months