Elmiron — Blue Cross Blue Shield of Alabama

Preferred products

• amitriptyline
• cimetidine
• hydroxyzine

Initial criteria

• The requested agent will be used for the relief of bladder pain or discomfort associated with interstitial cystitis
• The patient has tried and had an inadequate response to behavioral modification or self-care practices
• The patient has ONE of the following: - Has tried and had an inadequate response to ONE prerequisite agent (i.e., amitriptyline, cimetidine, or hydroxyzine) - OR Has an intolerance or hypersensitivity to ONE prerequisite agent - OR Has an FDA labeled contraindication to ALL prerequisite agents
• The patient has had an eye exam with an eye specialist (e.g., optometrist, ophthalmologist) prior to starting the requested agent
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested agent (e.g., decreased bladder pain, decreased frequency or urgency of urination)
• The patient has had an eye exam with an eye specialist (e.g., optometrist, ophthalmologist) within the last 12 months
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 6 months; renewal 12 months