Amitiza (lubiprostone) – brand — Blue Cross Blue Shield of Montana
Constipation – brand vs generic preference
Preferred products
- lubiprostone (generic Amitiza)
Initial criteria
- Brand/generic table: Amitiza = lubiprostone
- If request is for brand agent with available generic, ONE of the following:
- A. BOTH of the following:
- 1. Stage four metastatic cancer diagnosis and appropriate use documented [chart notes required] AND
- 2. Use consistent with best practices, supported by evidence-based literature, FDA-approved OR
- B. Patient currently treated and stable on requested agent [chart notes required] OR
- C. Tried and inadequate response to generic equivalent [chart notes required] OR
- D. Generic discontinued for lack of efficacy, effect, or adverse event [chart notes required] OR
- E. Intolerance/hypersensitivity to generic not expected with brand [chart notes required] OR
- F. FDA labeled contraindication to generic not expected with brand [chart notes required] OR
- G. Generic expected ineffective or harmful based on patient/drug characteristics [chart notes required] OR
- H. Generic not in best interest of patient based on medical necessity [chart notes required] OR
- I. Tried another drug in same pharmacologic class discontinued due to lack of efficacy or adverse event [chart notes required] OR
- J. Support exists for use of requested brand agent over generic equivalent