CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dipentum (olsalazine) prior authorization

Prior authorization policy for Dipentum (olsalazine) for maintenance of remission of ulcerative colitis in adults intolerant of sulfasalazine. Defines coverage criterion required to approve the drug under prior authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDipentum (olsalazine) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDipentum will be covered only with prior authorization when criteria are met (maintenance of remission of ulcerative colitis in an adult intolerant of sulfasalazine).

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this update.

1Covered Indication(s)

Prior Authorization RequiredCoverage Condition

Coverage Summary

Prior authorization policy for Dipentum (olsalazine) for maintenance of remission of ulcerative colitis in adults intolerant of sulfasalazine. Dipentum is covered with prior authorization when used for maintenance of remission of ulcerative colitis in adult patients who are intolerant of sulfasalazine; the policy aligns with the FDA-approved label and standard drug information sources (package insert, Lexicomp, Micromedex).

Initial Therapy Criteria

Initial Prior Authorization / Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Requested drug is Dipentum (olsalazine).
Indication is maintenance of remission of ulcerative colitis.
Patient is an adult.
Patient is intolerant of sulfasalazine.

Unproven / Exclusions

No additional exclusions or not-covered scenarios are specified in the brief beyond the coverage criteria. Coverage is limited to the circumstances described in the prior authorization criteria (maintenance of remission of ulcerative colitis in an adult patient who is intolerant of sulfasalazine).

Provider Actions

Prior Authorization

Prior authorization required

Dipentum will be covered only with prior authorization when criteria are met (maintenance of remission of ulcerative colitis in an adult intolerant of sulfasalazine).

Prior authorization is required.
Prescriber determination that the patient is intolerant of sulfasalazine is acceptable.

Document clinical rationale for why the patient is considered intolerant of sulfasalazine when submitting the prior authorization request. The policy implies intolerance refers to an adverse reaction or inability to use sulfasalazine as judged by the prescriber, so include relevant intolerance documentation or prescriber explanation with the PA request.

Background

Dipentum (olsalazine) is FDA-approved for the maintenance of remission of ulcerative colitis in adult patients intolerant of sulfasalazine. The policy references the FDA label and standard drug information sources (package insert, Lexicomp, Micromedex).

Intolerant of sulfasalazine: Not explicitly defined in the policy; the term implies an adverse reaction to or inability to use sulfasalazine as judged by the prescriber.