- 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: Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Duration of IBS Symptoms Required: N/A
No Known Mechanical GI Obstruction: No
Documented Diagnosis: No
Documented Symptoms >= 3 Months: No
- Prior Authorization: Gastro: IBS-C:
PA Applies
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Step Therapy: Gastro: IBS-C:
Step Applies
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