CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 03/01/2021 VERIFIED: 03/30/2021 REVIEWED: 03/30/2021 IRRITABLE BOWEL SYNDROME/CHRONIC IDIOPATHIC CONSTIPATION Prior Authorization Override Request PHARMACY FAX # 844-256-2025 • Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _ NO _ YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy / /  No

(alosetron – generic of Lotronex) LINZESS (linaclotide) MOTEGRITY (prucalopride) MYTESI (crofelemer) TRULANCE (plecanatide) VIBERZI (eluxadoline) XIFAXAN (rifaximin) ZELNORM (tegaserod) DULOLAX PERI-COLACE MIRALAX KONSYL SENOKOT BENTYL LOMOTIL LOTRONEX

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1

2

3

4

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 03/01/2021 VERIFIED: 03/30/2021 REVIEWED: 03/30/2021 CRITERIA FOR APPROVAL

1 Is this request for Linzess 145mcg OR 290mcg capsule? Yes No [If no, then skip to question 4.]

2 Is this request for continuation of therapy? Yes No [If no, then skip to question 7.]

3 Has the provider submitted clinical documentation and rationale supporting that Yes No the member’s disease state is currently controlled on the requested medication? [Note: Documentation is required for approval.]

[If no, then skip to question 7.]

4 Is this request for any of the following: A) Linzess 72mcg B) Motegrity, C) Yes No Trulance? [If yes, then skip to question 12.]

5 Is this request for Zelnorm? Yes No [If no, then skip to question 7.]

6 Is the requested drug being prescribed for a woman 64 years of age or younger? Yes No [If yes, then skip to question 12.]

7 Has the patient experienced an inadequate treatment response with no less than Yes No a 14 day trial of TWO preferred medications (which do not require prior approval)? [If yes, then skip to question 9.]

8 Is the patient unable to be changed to a preferred medication (which does not Yes No require prior approval) for any of the following acceptable reasons: A) Allergy, B) Contraindication or drug interaction, C) History of unacceptable or toxic side effects? [If no, then no further questions.]

9 Is the patient 18 years of age or older? Yes No [If no, then no further questions.] 10 Is this request for Mytesi? Yes No [If no, then no further questions.] 11 Does the patient have a diagnosis of non-infectious diarrhea and evidence of Yes No concurrent HIV antiviral therapy? [No further questions]

12 Has the patient experienced an inadequate treatment response with no less than Yes No a 14 day trial of TWO step therapy products (i.e. Amitiza and Linzess 145mcg and 290mcg)? [Note: Step therapy product approval requires trial and failure or inability to use at least TWO preferred medications (not requiring prior approval).]

[If yes, then skip to question 14.]

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 03/01/2021 VERIFIED: 03/30/2021 REVIEWED: 03/30/2021 13 Is the patient unable to be changed to a preferred medication for any of the Yes No following acceptable reasons: A) Allergy, B) Contraindication or drug interaction, C) History of unacceptable or toxic side effects? [If no, then no further questions.]

14 Is the patient 18 years of age or older? Yes No

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)*

*In order to process this request, please complete all boxes completely.

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