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Drug - Zurampic® (lesinurad) [AstraZeneca Pharmaceuticals]

January 2017

Therapeutic Area - Antihyperuricemics

Approval criteria

  • Patient is 18 years of age or older AND
  • Has symptomatic hyperuricemia associated with gout AND
  • Has had adequate trial of a xanthine oxidase inhibitor (at least 3 months) as documented in pharmacy fill history or chart notes indicating fill/refill history if patient is new to Medical Assistance and pharmacy claims data is not readily available AND
  • Has a documented serum uric acid > 6.5 mg/dL AND
  • Patient will use lesinurad concurrently with a xanthine oxidase inhibitor (e.g. allopurinol, febuxostat) AND
    • If allopurinol: dose of allopurinol should be > 300 mg daily or >200 mg daily in patients with CrCL < 60 mL/min

Denial criteria

  • Patient is prescribed Zurampic as monotherapy OR
  • Patient has one of the following conditions:
    • Severe renal impairment (CrCl < 45 mL/min)
    • End stage renal disease
    • On dialysis
    • Kidney transplant
    • Tumor lysis syndrome or Lesch-Nyhan syndrome

Quantity limit

34 tablets per 34 days


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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