Viberzi (eluxadoline) — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Viberzi is prescribed by or in consultation with a gastroenterologist or a physician who specializes in the management of gastrointestinal disease; AND
• Patient has attempted lifestyle changes, including maintaining a diet rich in fiber and/or fiber supplementation; AND
• Patient has failed or is intolerant to at least 2 of the following in the past three months: at least one antidiarrheal agent (e.g. loperamide); OR at least one antispasmodic agent (e.g. dicyclomine); OR at least one tricyclic antidepressant (e.g. amitriptyline); AND
• Patient has tried Xifaxan OR alosetron tablets (Lotronex, generics); AND
• Patient is not taking medications that may lead to severe constipation (e.g. Lotronex [alosetron], anticholinergic medications, and opioids); AND
• Patient does not have a known or suspected history of any of the following conditions: gallbladder removal; OR alcoholism, alcohol abuse, alcohol addiction, or consumption of more than 3 alcoholic drinks daily; OR biliary duct obstruction; OR sphincter of Oddi disease; OR severe hepatic impairment (Child-Pugh Class C); OR pancreatitis; OR severe constipation; OR gastrointestinal obstruction.

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Viberzi is prescribed by or in consultation with a gastroenterologist or a physician who specializes in the management of gastrointestinal disease; AND
• Patient has demonstrated a beneficial response to Viberzi, per the prescribing physician (e.g. improved stool consistency from baseline); AND
• Patient has no contraindications to Viberzi.

Approval duration

initial 180 days; reauth 365 days