Thyquidity™ (Levothyroxine Oral Solution), Tirosint® (Levothyroxine Capsule), and Tirosint®-SOL (Levothyroxine Oral Solution) Approval Criteria:
- An FDA approved diagnosis of one of the following:
- Hypothyroidism: As replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism; OR
- Pituitary Thyrotropin (Thyroid-Stimulating Hormone, TSH) Suppression: As an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer; AND
- A patient-specific, clinically significant reason why the member cannot use all other formulations of levothyroxine sodium must be provided. For the oral solution, a reason why the member cannot use the levothyroxine tablet formulation, even when the tablets are crushed, must be provided; AND
- Prescriber must verify member has been compliant with levothyroxine tablets at a greatly increased dose for at least 8 weeks; AND
- Prescriber must verify that member has not been able to achieve normal thyroid lab levels despite a greatly increased dose and compliance with levothyroxine tablets.
Prior Authorization form