- Prior Authorization: Gastro: IBS-C:
PA Applies
- Step Therapy: Gastro: IBS-C:
Step Applies
- Chronic Idiopathic Constipation:
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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
Patient has known or suspected mechanical obstruction: No
Symptoms > 3 months: No
Failure of 1 conventional laxative therapy: Yes
Failure of 2 conventional laxative therapies: No
Failure of 3 conventional laxative therapies: No
Gastro: IBS-C: 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
Documented Diagnosis: Yes
Documented Symptoms >= 3 Months: No
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