Elmiron — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient has tried and had an inadequate response to behavioral modification or self-care practices AND
• The patient has ONE of the following: A. Has tried and had an inadequate response to ONE prerequisite agent (amitriptyline, cimetidine, or hydroxyzine) OR B. Has an intolerance or hypersensitivity to ONE prerequisite agent OR C. Has an FDA labeled contraindication to ALL prerequisite agents AND
• The patient has had an eye exam with an eye specialist (e.g., optometrist, ophthalmologist) prior to starting the requested agent AND
• 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 AND
• The patient has had clinical benefit with the requested agent (e.g., decreased bladder pain, decreased frequency or urgency of urination) AND
• The patient has had an eye exam with an eye specialist (e.g., optometrist, ophthalmologist) within the last 12 months AND
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

6 months initial, 12 months renewal