Gastro-Intestinal 2019
Tier 1 products are available with no authorization necessary. Criteria for Approval of a Tier 2 medication:
Criteria for Approval of a Tier 3 medication:
Pediatric members under the age of 19 approval criteria:
Special Prior Authorizations of Miscellaneous Products: ***Special Formulations including ODTs, Granules, Suspension and Solution for I.V. require special reason for use. famotidine suspension (Pepcid®) Approval Criteria:
glycopyrrolate tablet (Glycate®) Approval Criteria:
nizatidine solution (Axid®):
nizatidine capsules (Axid®) and cimetidine tablets (Tagamet®):
ESOMEP-EZS™ (esomeprazole kit) Approval Criteria:
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Tier 1 |
Tier 2 |
Tier 3 |
Special PA* |
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lubiprostone (Amitiza®) | ||
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PA criteria: Amitiza® (Lubiprostone) Approval Criteria – Chronic Idiopathic Constipation (CIC) or Irritable Bowel Syndrome:
Amitiza® (Lubiprostone) Approval Criteria – Opioid-Induced Constipation (OIC):
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linaclotide (LinzessTM) | ||
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PA criteria:
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difenoxin/atropine (Motofen®) | ||
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PA criteria:
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naldemedine (Symproic®) | ||
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PA criteria:
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naloxegol (Movantik™) | ||
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PA criteria:
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plecanatide (Trulance™) | ||
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PA criteria:
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telotristat ethyl (Xermelo™) | ||
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PA criteria:
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methylnaltrexone bromide (Relistor®) | ||
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PA criteria:
Relistor® (Methylnaltrexone) Injection Approval Criteria (Chronic Non-Cancer Pain Diagnosis):
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bezlotoxumab (Zinplava™) |
bezlotoxumab (Zinplava™) Approval Criteria:
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If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.