Amitiza (lubiprostone) — Blue Cross Blue Shield of Texas

Irritable Bowel Syndrome with Constipation (IBS-C)

Preferred products

ONE of the following: the requested agent is Ibsrela (tenapanor) OR the requested agent is Amitiza (lubiprostone) AND ONE of the following: (1) the patient’s sex is female OR (2) the requested agent is medically appropriate for the patient’s sex and intended diagnosis
AND ONE of the following: (A) BOTH of the following: (1) ONE of the following: (A) the prescriber has stated the patient has stage four advanced metastatic cancer and the agent is being used to treat the cancer OR (B) documentation of stage four advanced metastatic cancer and use for associated condition is submitted AND (2) the use is consistent with best practices, evidence-based literature, and FDA approval OR (B) the patient has tried and had an inadequate response to ≥2 standard laxative therapy classes (e.g., bulk forming, stimulant, enema, osmotic, stool softener) OR (C) intolerance/hypersensitivity to ≥2 standard laxative classes OR (D) FDA labeled contraindication to ALL standard laxative classes