Azasan — Medical Mutual

Preferred products

• Generic azathioprine
• Generic cyclosporine
• Generic everolimus
• Generic mycophenolate
• Generic mycophenolic acid
• Generic sirolimus
• Generic tacrolimus
• Gengraf

Initial criteria

• If the patient has tried a preferred medication, then authorization for a non-preferred medication may be given
• If the patient is younger than age < 12 OR has a documented inability to swallow solid dosage forms, approve Myhibbin oral suspension
• Step Therapy Exception Criteria: Approve if ANY of the following:
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents (must list diagnosis and/or patient characteristics)
• B. The patient has a contraindication to all preferred agents (must list contraindications to each preferred agent)
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• 1. The patient has at least 130 days of prescription claims history and has received the requested non-preferred agent for 90 days within the 130-day look-back period AND there is no generic equivalent (AA-rated or AB-rated) available for the requested non-preferred product
• 2. If 130 days of claims history is unavailable, prescriber verification that the patient has been receiving the requested non-preferred agent for 90 days via paid claims (not samples or coupons) AND that there is no generic equivalent (AA-rated or AB-rated) available for the requested non-preferred product

Reauthorization criteria

• Continuation of therapy may be approved for 1 year

Approval duration

1 year