Lotronex (alosetron) — Highmark
severe, chronic irritable bowel syndrome with diarrhea (IBS-D) in adult women
Preferred products
- generic alosetron
Initial criteria
- age ≥ 18 years
- female patient
- diagnosis of irritable bowel syndrome with diarrhea (IBS-D) (ICD-10: K58.0) classified as severe and chronic
- experienced therapeutic failure or intolerance to one (1) agent from two (2) different medication classes (anti-diarrheal, anti-spasmodic, tricyclic antidepressant) OR all are contraindicated
- if request is for brand Lotronex, experienced therapeutic failure or intolerance to generic alosetron
Reauthorization criteria
- IBS-D symptoms continue to persist
- experienced positive clinical response to therapy
- if request is for brand Lotronex, experienced therapeutic failure or intolerance to generic alosetron
Approval duration
initial up to 12 weeks; reauthorization up to 12 months