Viberzi (eluxadoline) — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of irritable bowel syndrome with diarrhea (IBS-D) (ICD-10: K58.0)
• therapeutic failure or intolerance to one (1) agent from any of the following medication classes, or all are contraindicated: anti-diarrheal (e.g., loperamide) OR anti-spasmodic (e.g., dicyclomine, hyoscyamine) OR tricyclic antidepressant (e.g., amitriptyline, nortriptyline)
• member does not have any of the following: gallbladder removed, severe (Child-Pugh C) hepatic impairment, or alcohol abuse (more than 3 drinks per day)

Reauthorization criteria

• provider attests that the member’s IBS-D symptoms continue to persist
• provider attests that the member has experienced positive clinical response to therapy

Approval duration

12 months