Trelstar Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

PA applies to new starts only

Trelstar will be approved when ALL of the following are met:

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND

2. ONE of the following:

   1. There is evidence of a claim that the patient has been treated with the requested medication within the past 180 days
      OR

   2. The prescriber states the patient is currently being treated with the requested medication
      OR

   3. BOTH of the following:

      1. The patient is NOT currently being treated with the requested medication
         AND
      2. The patient does NOT have any FDA labeled contraindications to the requested medication
         AND

3. The requested dose is within FDA labeled dosing or supported in CMS approved compendia dosing for the requested indication

Length of Approval: 12 months