Vesicare LS — Highmark

Preferred products

• generic oxybutynin
• generic oxybutynin ER

Initial criteria

• If the request is for Vesicare LS, the member is 2 to 17 years of age
• If the request is for Myrbetriq granules, the member is 3 to 17 years of age
• The member has a diagnosis of neurogenic detrusor overactivity
• If the member is 6 years of age or older, the member has experienced therapeutic failure, contraindication, or intolerance to generic oxybutynin or generic oxybutynin ER

Reauthorization criteria

• The prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

12 months