Subject: Dipentum PA Policy 2967-A 02-2023

Drug

DIPENTUM  (olsalazine)

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

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Dipentum [package insert]. Somerset, New Jersey: Meda Pharmaceuticals Inc.; December 2022.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Hudson, Ohio: UpToDate, Inc.; 2023; Accessed January 5, 2023.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed January 5, 2023.

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.

August 13, 2023