Ibsrela (tenapanor) — Blue Cross Blue Shield of Montana
Irritable Bowel Syndrome with Constipation (IBS-C)
Preferred products
- Trulance (plecanatide)
- Linzess (linaclotide)
Initial criteria
- The requested agent is Ibsrela (tenapanor) OR the requested agent is Amitiza (lubiprostone) AND ONE of the following:
- • The patient's sex is female OR
- • The requested agent is medically appropriate for the patient's sex and the intended diagnosis AND ONE of the following:
- A. BOTH of the following:
- 1. ONE of the following:
- a. The prescriber has stated or documented a diagnosis of stage four advanced, metastatic cancer and requested agent is being used to treat the cancer OR an associated condition [chart notes required] AND
- 2. The use of the requested agent is consistent with best practices; supported by peer-reviewed, evidence-based literature; and FDA-approved OR
- B. The patient has tried and had an inadequate response to at least 2 standard laxative therapy classes (e.g., bulk forming, stimulant, enema, osmotic, stool softener) OR
- C. The patient has an intolerance or hypersensitivity to at least 2 standard laxative therapy classes OR
- D. The patient has an FDA labeled contraindication to ALL standard laxative therapy classes