- Health Net Approved Indications and Usage Guidelines: 1.Traveler's Diarrhea; a.Patient is 18 years or older with traveler's diarrhea and failure or clinically; significant adverse effects to ciprofloxacin; OR b.Patient is 12-17 years of age with traveler's diarrhea; 2.Hepatic Encephalopathy; a.Treatment or prophylaxis of hepatic encephalopathy and failure or clinically significant adverse effects to lactulose; 3.Small Intestinal Bacterial Overgrowth; a.Patient has small intestinal bacterial overgrowth; 4.Crohn's Disease; a.Patient has Crohn's Disease and failure or clinically significant adverse reaction to metronidazole or ciprofloxacin; 5.IBSD (Irritable Bowel Syndrome with Diarrhea); a.Patient has irritable bowel syndrome with diarrhea; AND b.Failure of or clinically significant adverse effects to two of the following: i. Bulk forming agent (e.g., psyllium); ii. Anti-diarrhea agent (e.g., bismuth subsalicylate, loperamide); iii. Antispasmodic agent (e.g., diphenoxylate-atropine, dicyclomine, hyoscyamine, hyoscyamine/atropine/scopolamine/phenobarbital).
- Gastro: IBS-D:
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):
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented Diagnosis: Yes
- Step Therapy Exists in PA
- Step Therapy: Gastro: IBS-D:
ST Multiple Generics
Hepatic Encephalopathy (HE):
ST Single Generic
- Prior Authorization: Gastro: IBS-D:
PA Applies
Hepatic Encephalopathy (HE):
Documented Diagnosis: Yes
- Quantity Limit: limit maximum 9 EA PER fill retail
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