- Prior Authorization: Duration: 12 Month(s)
- Step Therapy: ST Multiple Generics
- Quantity Limit: 9 tablets per 1 fill(s).
- Gastro: IBS-D:
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
REMs Program Criteria Included: No
Policy States Patient Must Have a Documented Trial and Failure of Diet, Exercise and Counseling: No
Documented Diagnosis: No
Chronic IBS Symptoms for 6 Months or Longer: No
Non-pharmacologic Therapy: No
Patient Must Have Documented Symptoms of Loose Watery Stools: No
Hepatic Encephalopathy (HE):
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: No
Documented Diagnosis: No
- PA Applies
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
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