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Amitiza (lubiprostone) — Blue Cross Blue Shield of Montana

Chronic Idiopathic Constipation (CIC)

Preferred products

  • Trulance (plecanatide)
  • Linzess (linaclotide)

Initial criteria

  • The patient has a diagnosis of chronic idiopathic constipation (CIC) AND all of the following:
  • 1. Symptoms present ≥ 3 months
  • 2. Requested agent is Amitiza (lubiprostone) or Motegrity (prucalopride)
  • 3. ONE of the following:
  • A. BOTH of the following:
  • 1. ONE of the following:
  • a. Prescriber stated/documented stage four metastatic cancer and agent used for cancer or associated condition [chart notes required] AND
  • 2. Use consistent with best practices, supported by peer-reviewed evidence, FDA-approved OR
  • B. Tried and inadequate response to ≥2 laxative classes (bulk forming, stimulant, enema, osmotic, stool softener) OR
  • C. Intolerance/hypersensitivity to ≥2 laxative classes OR
  • D. FDA labeled contraindication to ALL standard laxative classes