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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAgency Health Care Constipation Coverage | OpenPay…
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    CurrentAgency for Health Care AdministrationPolicy N/A

    Constipation Treatment Agents

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    This policy governs prior authorization for selected prescription constipation treatment agents, including criteria for chronic idiopathic constipation, irritable bowel syndrome with constipation, and opioid-induced constipation. It applies to providers seeking coverage for eligible patients under the plan.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyConstipation Treatment Agents
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a trial and failure or intolerance to lactulose within the past month before requesting non-preferred therapy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≥18 yearsMinimum patient age
    Past monthLactulose trial history
    1 yearMaximum authorization length
    3Covered indication categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria Overview

    Initial Therapy Criteria

    Covered when all applicable requirements are met.

    Initial therapy requirements

    • General requirements

      • The patient is at least 18 years of age.Age ≥18 years
      • Dosing is appropriate as per labeling or is supported by compendia or standard-of-care guidelines.

    • Covered indication

      • Chronic idiopathic constipation or irritable bowel syndrome with constipation

        • The patient has a confirmed diagnosis of chronic idiopathic constipation or irritable bowel syndrome with constipation.
        • The patient has a history within the past month of trial and failure or intolerance to lactulose.Within the past month

          Documentation required.

        • The patient has tried and failed one preferred agent or has a medical reason why the patient is unable to use the preferred product.

          Documentation required.

      • Opioid-induced constipation

        • The patient has a documented history within the past month of an advanced illness requiring chronic opioid use, or has a confirmed diagnosis of opioid-induced constipation with chronic non-cancer pain.Within the past month
        • The patient has a history within the past month of trial and failure or intolerance to lactulose.Within the past month

          Documentation required.

        • The patient has tried and failed one preferred agent or has a medical reason why the patient is unable to use the preferred product.

          Documentation required.

    Continuation Therapy Criteria

    Continuation therapy is covered when all requirements are met.

    Continuation therapy requirements

    • The patient met the initial review criteria.
    • Documentation demonstrates a positive clinical response.
    • Dosing is appropriate as per labeling or is supported by compendia or standard-of-care guidelines.

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Initial Prior Authorization Required

    Prior authorization is required for non-preferred constipation treatment agents. Initial authorization requests must document that the patient meets the applicable review criteria, including age, diagnosis, treatment history, and appropriate dosing.

    • Patient must be 18 years of age or older.
    • Dosing must be appropriate according to labeling or supported by compendia or standard-of-care guidelines.
    Prior Authorization

    Continuation Authorization Requirements

    For continuation of therapy, the patient must have met the initial review criteria and the request must demonstrate an ongoing positive clinical response. Dosing must remain appropriate according to labeling or supported by compendia or standard-of-care guidelines.

    • Document that the patient met the initial review criteria.
    • Document a positive clinical response to therapy.
    • Confirm appropriate dosing.
    Step Therapy

    Required Treatment Sequencing

    Follow the required treatment sequence before requesting authorization for a non-preferred agent: the patient must first trial and fail or be intolerant to lactulose, followed by a trial and failure of one preferred agent, unless there is a documented medical reason the patient is unable to use the preferred agent.

    • For CIC or IBS-C, a preferred agent may include Linzess (linaclotide).
    • For OIC, a preferred agent may include Movantik (naloxegol).
    • Document the medical reason when the patient is unable to use the preferred agent.
    Documentation Required

    Qualifying Diagnosis

    Document a confirmed covered diagnosis for the requested treatment: chronic idiopathic constipation (CIC), irritable bowel syndrome with constipation (IBS-C), or opioid-induced constipation (OIC).

    • For CIC or IBS-C, document the confirmed diagnosis.
    • For OIC, document the confirmed diagnosis and applicable opioid-use history.
    Step Therapy

    Lactulose Trial Required

    Document a trial and failure or intolerance to lactulose completed within the past month before requesting initial authorization.

    • Documentation of the lactulose trial and failure or intolerance is required.
    • The trial must have occurred within the past month.
    Documentation Required

    Preferred-Agent History

    Document that the patient has tried and failed one preferred agent, or provide a medical reason the patient is unable to use the preferred product.

    • For CIC or IBS-C, a preferred agent may include Linzess (linaclotide).
    • For OIC, a preferred agent may include Movantik (naloxegol).
    • Documentation is required for trial and failure or for the medical reason the preferred agent cannot be used.
    Documentation Required

    Opioid-Induced Constipation Documentation

    For OIC requests, document either an advanced illness, such as cancer, requiring chronic opioid use within the past month, or a confirmed diagnosis of OIC associated with chronic non-cancer pain.

    • Document the qualifying advanced illness and chronic opioid use, or confirmed OIC with chronic non-cancer pain.
    • The applicable history must be documented within the past month.
    Denial Risk

    Failure to Meet Initial Criteria

    An initial authorization request may be denied when the patient does not meet the applicable review criteria or the required documentation is absent.

    • Patient is younger than 18 years of age.
    • No confirmed CIC, IBS-C, or OIC diagnosis is documented.
    • A lactulose trial and failure or intolerance within the past month is not documented.
    • Trial and failure of one preferred agent, or a documented medical reason the patient cannot use it, is not documented.
    • For OIC, qualifying advanced illness with chronic opioid use or confirmed OIC with chronic non-cancer pain is not documented.
    • Requested dosing is not appropriate according to labeling, compendia, or standard-of-care guidelines.
    Denial Risk

    Failure to Meet Continuation Criteria

    A continuation request may be denied when the patient did not meet initial criteria, when positive clinical response is not documented, or when dosing is not appropriate.

    • Initial review criteria were not met or cannot be verified.
    • Positive clinical response to therapy is not documented.
    • Dosing is not appropriate according to labeling or is not supported by compendia or standard-of-care guidelines.

    Policy Background

    This policy addresses pharmacologic treatment of constipation-related disorders, including chronic idiopathic constipation, irritable bowel syndrome with constipation, and opioid-induced constipation. Coverage for non-preferred agents is structured around prior use of lactulose and, unless medically inappropriate, a preferred treatment agent. For opioid-induced constipation, eligibility distinguishes patients with an advanced illness requiring chronic opioid use from those with chronic non-cancer pain.

    Condition Definitions

    Chronic Idiopathic Constipation (CIC)
    TermCIC — chronic idiopathic constipation
    Covered indicationA confirmed diagnosis of chronic idiopathic constipation qualifies as a covered indication.
    Related authorization requirementDocumentation must show a trial and failure or intolerance to lactulose within the past month and a trial and failure of one preferred agent, unless there is a medical reason the patient cannot use it.
    Irritable Bowel Syndrome with Constipation (IBS-C)
    TermIBS-C — irritable bowel syndrome with constipation
    Covered indicationA confirmed diagnosis of irritable bowel syndrome with constipation qualifies as a covered indication.
    Related authorization requirementDocumentation must show a trial and failure or intolerance to lactulose within the past month and a trial and failure of one preferred agent, unless there is a medical reason the patient cannot use it.
    Opioid-Induced Constipation (OIC)
    TermOIC — opioid-induced constipation
    Qualifying clinical contextOpioid-induced constipation must be associated with either an advanced illness requiring chronic opioid use or chronic non-cancer pain.
    Related authorization requirementDocumentation must show the qualifying opioid-related history, a trial and failure or intolerance to lactulose within the past month, and a trial and failure of one preferred agent unless there is a medical reason the patient cannot use it.

    Initial Therapy Requirements

    Initial Therapy Criteria

    Covered when all applicable requirements are met.

    Initial therapy requirements

    • General requirements

      • The patient is at least 18 years of age.Age ≥18 years
      • Dosing is appropriate as per labeling or is supported by compendia or standard-of-care guidelines.

    • Covered indication

      • Chronic idiopathic constipation or irritable bowel syndrome with constipation

        • The patient has a confirmed diagnosis of chronic idiopathic constipation or irritable bowel syndrome with constipation.
        • The patient has a history within the past month of trial and failure or intolerance to lactulose.Within the past month

          Documentation required.

        • The patient has tried and failed one preferred agent or has a medical reason why the patient is unable to use the preferred product.

          Documentation required.

      • Opioid-induced constipation

        • The patient has a documented history within the past month of an advanced illness requiring chronic opioid use, or has a confirmed diagnosis of opioid-induced constipation with chronic non-cancer pain.Within the past month
        • The patient has a history within the past month of trial and failure or intolerance to lactulose.Within the past month

          Documentation required.

        • The patient has tried and failed one preferred agent or has a medical reason why the patient is unable to use the preferred product.

          Documentation required.

    Continuation Therapy Requirements

    Continuation Therapy Criteria

    Continuation therapy requires that all requirements are met.

    Continuation requirements

    • The patient met the initial review criteria.
    • Documentation demonstrates a positive clinical response.
    • Dosing is appropriate as per labeling or is supported by compendia or standard-of-care guidelines.

    Required Treatment Sequence

    StepRequired trial or exceptionTiming / documentation
    1Trial and failure or intolerance to lactulose before non-preferred therapyWithin the past month; documentation required
    2Trial and failure of one preferred agentDocumentation required
    Exception to step 2A medical reason why the patient is unable to use the preferred productDocument the medical reason
    Policy Summary
    PayerAgency for Health Care Administration
    PolicyConstipation Treatment Agents
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument a trial and failure or intolerance to lactulose within the past month before requesting non-preferred therapy.
    SourceLink
    On This Page
    Coverage Criteria OverviewPrior Authorization and Documentation RequirementsPolicy BackgroundCondition DefinitionsInitial Therapy RequirementsContinuation Therapy RequirementsRequired Treatment Sequence