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Motegrity (prucalopride) — Blue Cross Blue Shield of New Mexico

irritable bowel syndrome with constipation (IBS-C)

Preferred products

  • Trulance (plecanatide)
  • Linzess (linaclotide)
  • Symproic (naldemedine)
  • Movantik (naloxegol)

Initial criteria

  • One of the following: the requested agent is Ibsrela (tenapanor) OR the requested agent is Amitiza (lubiprostone) AND one of the following: (a) the patient's sex is female OR (b) the requested agent is medically appropriate for the patient's sex and intended diagnosis
  • Stage four advanced metastatic cancer exception: prescriber documentation that the patient has stage four advanced, metastatic cancer and the requested agent is used to treat the cancer or an associated condition AND the use is consistent with best practices, peer-reviewed, evidence-based, and FDA-approved
  • OR the patient has tried and had an inadequate response to at least 2 standard laxative therapy classes (bulk forming, stimulant, enema, osmotic, or stool softener)
  • OR the patient has an intolerance or hypersensitivity to at least 2 standard laxative therapy classes
  • OR the patient has an FDA labeled contraindication to all standard laxative therapy classes
  • For chronic idiopathic constipation (CIC): patient has CIC symptoms for ≥3 months AND the requested agent is Amitiza (lubiprostone) or Motegrity (prucalopride) AND one of the following: same options as above (stage 4 cancer exception, inadequate laxative response, intolerance, or contraindication)
  • For opioid-induced constipation (OIC): one of the following—(A) the requested agent is Relistor (methylnaltrexone) tablet OR Amitiza (lubiprostone) AND the patient is not receiving methadone AND has chronic pain (non-cancer, cancer-related, or active cancer) OR (B) Relistor (methylnaltrexone) injection and patient is receiving palliative care with advanced illness or active cancer pain
  • Patient has chronic opioid use in past 30 days
  • AND one of the following: (a) stage four advanced metastatic cancer exception as above OR (b) inadequate response to ≥2 standard laxative classes (stimulant, enema, osmotic, stool softener, excluding fiber agents) OR (c) intolerance/hypersensitivity to ≥2 laxative classes OR (d) FDA labeled contraindication to all laxative classes
  • If FDA indication, one of the following: patient age within FDA label OR supported use for patient’s age
  • For brand Amitiza (lubiprostone): one of the following—(A) stage four advanced metastatic cancer exception as above; OR (B) patient currently stable on the requested agent; OR (C) inadequate response to generic; OR (D) generic discontinued for lack of efficacy/effectiveness or adverse event; OR (E) intolerance/hypersensitivity to generic not expected to occur with brand; OR (F) contraindication to generic not expected to occur with brand; OR (G) generic expected to be ineffective or cause adherence barrier, worsen comorbidity, decrease function, cause adverse reaction; OR (H) generic not in best interest due to medical necessity; OR (I) other drug in same class discontinued for lack of efficacy or adverse event; OR (J) there is support for brand use over generic
  • For use in IBS-C or CIC: one of the following—(A) stage four advanced metastatic cancer exception; OR (B) patient stable on requested agent; OR (C) inadequate response to Trulance (plecanatide) and Linzess (linaclotide); OR (D) Trulance and Linzess discontinued due to inefficacy or adverse event; OR (E) intolerance/hypersensitivity to Trulance and Linzess not expected to occur with requested agent; OR (F) contraindication to Trulance and Linzess not expected to occur with requested agent; OR (G) Trulance and Linzess expected ineffective or cause adherence barrier, worsen comorbidity, decrease function, cause harm; OR (H) not in best interest based on medical necessity; OR (I) another drug in same class discontinued due to inefficacy or adverse event
  • For OIC: one of the following—(A) stage four advanced metastatic cancer exception; OR (B) patient stable on requested agent; OR (C) inadequate response to Symproic (naldemedine) and Movantik (naloxegol); OR (D) Symproic and Movantik discontinued due to inefficacy or adverse event; OR (E) intolerance/hypersensitivity to Symproic and Movantik not expected with requested agent; OR (F) contraindication to Symproic and Movantik not expected with requested agent