UnitedHealthcare
Viberzi (eluxadoline)
Drugs for the Stomach : Drugs for Irritable Bowel Syndrome
  • Prior Authorization: Gastro: IBS-D:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: limit maximum 2 EA PER 1 day(s)
  • Step Therapy: Gastro: IBS-D:
    ST Multiple Generics

  • Gastro: IBS-D:
    Duration: 6 Month(s)
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Duration of IBS Symptoms Required: N/A
    REMs Program Criteria Included: No
    Policy States Patient Must Have a Documented Trial and Failure of Diet, Exercise and Counseling: No
    Documented Requirement of Loose Watery Stools Percentage (%): N/A
    Documented Diagnosis: Yes
    Chronic IBS Symptoms for 6 Months or Longer: No
    Non-pharmacologic Therapy: No
    Patient Must Have Documented Symptoms of Loose Watery Stools: No

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