- Step Therapy: Step Applies
- Prior Authorization: PA Applies
- Chronic Idiopathic Constipation:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Patient does not have known or suspected mechanical obstruction: No
Diagnosis of severe CIC: No
Duration Required for Patient to Have Symtoms of CIC: N/A
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Patient has known or suspected mechanical obstruction: No
Symptoms > 3 months: No
Failure of 1 conventional laxative therapy: No
Failure of 2 conventional laxative therapies: No
Failure of 3 conventional laxative therapies: Yes
Gastro: IBS-C:
Age Requirement: >= 18
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Duration of IBS Symptoms Required: N/A
No Known Mechanical GI Obstruction: No
Supporting Documentation Requirements: Chart Notes
Documented Diagnosis: Yes
Documented Symptoms >= 3 Months: No
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