Ibsrela (tenapanor) — Blue Cross Blue Shield of Oklahoma
irritable bowel syndrome with constipation (IBS-C)
Preferred products
- Trulance (plecanatide)
- Linzess (linaclotide)
Initial criteria
- ONE of the following: 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: BOTH of the following: ONE of the following: prescriber statement or documentation that patient has stage four advanced, metastatic cancer and agent is used to treat the cancer or an associated condition AND use is consistent with best practices and FDA approval OR 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 patient has intolerance or hypersensitivity to at least 2 standard laxative classes OR patient has FDA labeled contraindication to ALL standard laxative therapy classes