Prior Auth Protocol

Prior Authorization Protocol

XURIDEN^TM (uridine triacetate)

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- Xuriden is a pyrimidine analog for uridine replacement indicated for the treatment of hereditary orotic aciduria.
Health Net Approved Indications and Usage Guidelines:
- Diagnosis of hereditary orotic aciduria
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:

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Therapeutic Alternatives:

Drug Dosing Regimen Dose Limit/ Maximum Dose
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* Requires Prior Authorization
Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
Xuriden
60 mg/kg to 120 mg/kg PO QD (max of 8 gms per day)
Length of Benefit
Product Availability:

Oral granules: 2 gm packets
References:

1. Xuriden [Prescribing Information]. Gaithersburg, MD: Wellstat Therapeutics Corp.; September 2015.

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
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Drug	Dosing Regimen	Authorization Limit
Xuriden	60 mg/kg to 120 mg/kg PO QD (max of 8 gms per day)	Length of Benefit

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.