Subject: Dipentum PA 2967-A 07-2022
Policy:
FDA-approved Indications
Dipentum is indicated for the maintenance of remission of ulcerative colitis in adult patients who are intolerant of sulfasalazine.
COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
• The requested drug is being prescribed for the maintenance of
remission of ulcerative colitis in a patient who is intolerant of
sulfasalazine
RATIONALE
The intent of the criteria is to provide coverage consistent with product labeling, FDA guidance, standards of medical practice, evidence-based drug information, and/or published guidelines. Dipentum is indicated for the maintenance of remission of ulcerative colitis in patients who are intolerant of sulfasalazine.
Place of Service:
Outpatient
The above policy is based on the following references:
- Dipentum [package insert]. Somerset, New Jersey: Meda Pharmaceuticals Inc.; October 2021.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Hudson, Ohio: UpToDate, Inc.; 2022; Accessed June 6, 2022.
- Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed June 6, 2022.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
December 10, 2022
