mesalamine delayed release 800 mg — Medical Mutual

Preferred products

• balsalazide disodium 750 mg
• sulfasalazine and sulfasalazine delayed release 500 mg
• mesalamine 1.2 g delayed release tablets (generic)
• mesalamine 0.375 g extended release capsules (generic)
• mesalamine 400 mg delayed release capsules (generic)
• mesalamine 500 mg controlled-release capsules (generic)
• Pentasa (mesalamine controlled-release) 250 mg and 500 mg
• Apriso (with DAW9)

Initial criteria

• If the patient has tried a preferred medication, then authorization for a non-preferred medication may be given

Reauthorization criteria

• The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents OR
• The patient has a contraindication to all preferred agents OR
• The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND ONE of the following:
• 1. Claims history supports patient has received the requested non-preferred agent for 90 days within a 130-day look-back period AND no generic equivalent is available OR
• 2. Prescriber verifies patient has been receiving the requested non-preferred agent for 90 days with paid claims (not samples/coupons) AND no generic equivalent is available

Approval duration

1 year; 2 years if criteria for step-therapy trial are met