- Step Therapy: Gastro: IBS-D:
ST Multiple Generics
- Gastro: IBS-D:
Age Requirement: >= 18
Duration: 1 plan year
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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
Supporting Documentation Requirements: Chart Notes
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
- Prior Authorization: Gastro: IBS-D:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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