Zurampic
Drug - Zurampic® (lesinurad) [AstraZeneca Pharmaceuticals]
January 2017
Therapeutic Area - Antihyperuricemics
Approval criteria
- Patient is 18 years of age or older AND
- Has symptomatic hyperuricemia associated with gout AND
- Has had adequate trial of a xanthine oxidase inhibitor (at least 3 months) as documented in pharmacy fill history or chart notes indicating fill/refill history if patient is new to Medical Assistance and pharmacy claims data is not readily available AND
- Has a documented serum uric acid > 6.5 mg/dL AND
- Patient will use lesinurad concurrently with a xanthine oxidase inhibitor (e.g. allopurinol, febuxostat) AND
- If allopurinol: dose of allopurinol should be > 300 mg daily or >200 mg daily in patients with CrCL < 60 mL/min
Denial criteria
- Patient is prescribed Zurampic as monotherapy OR
- Patient has one of the following conditions:
- Severe renal impairment (CrCl < 45 mL/min)
- End stage renal disease
- On dialysis
- Kidney transplant
- Tumor lysis syndrome or Lesch-Nyhan syndrome
Quantity limit
34 tablets per 34 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411
