Mytesi (crofelemer) prior authorization form
A pharmacy prior authorization/step-edit request form for Mytesi (crofelemer) specifying required member/prescriber information and clinical criteria that must all be met for approval. It documents age, diagnosis, HIV status on ART, diarrhea type, and prior trial of specified antidiarrheal agents.
No material changes — policy content reflects an authorization form and approval criteria without recent substantive updates.
Coverage Summary
Mytesi (crofelemer) is covered with criteria: approved for adults ≥ 18 years who have non-infectious diarrhea associated with HIV/AIDS while on antiretroviral therapy, and who have tried at least one listed antidiarrheal agent (loperamide or diphenoxylate/atropine). Note that drug samples do not satisfy the prior therapy/step-edit requirement.
Approval Criteria for Mytesi (crofelemer)
All criteria must be met for approval. To support each line checked, documentation (lab results, diagnostics, chart notes) must be provided.
Applicable Codes
| No codes listed |
Provider Actions & Submission Requirements
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.