Envarsus XR (tacrolimus extended-release tablets) — United Healthcare
Prophylaxis of organ rejection in kidney transplant recipients
Preferred products
- tacrolimus immediate-release
Initial criteria
- Patient is the recipient of a kidney transplant
- AND One of the following: (1) Provider attests that the patient is not an appropriate candidate for immediate-release tacrolimus based on one of the following: i. Unable to achieve or maintain an appropriate therapeutic drug level with immediate-release tacrolimus ii. In the provider’s expert opinion, the patient would be unable to achieve or maintain an appropriate therapeutic drug level with immediate-release tacrolimus OR (2) Patient is currently on Envarsus XR therapy and the provider attests that switching therapy would be clinically inappropriate
- AND Envarsus XR will be used in combination with other immunosuppressant medications (e.g., mycophenolate, azathioprine, corticosteroids) to prevent organ rejection in kidney transplant recipients
- AND Prescribed by or in consultation with a nephrologist or transplant specialist
Approval duration
12 months