CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior Authorization Request Form — Overactive Bladder Agents (Detrol, Detrol LA, Ditropan XL, Oxytrol, Vesicare, Myrbetriq, Toviaz, Gelnique)

This document is a prior authorization request form for Detrol LA, Detrol, Ditropan XL, Oxytrol, Vesicare, Myrbetriq, Toviaz and related overactive bladder medications, used by providers to request coverage from OptumRx/Blue Cross Blue Shield - South Carolina. It affects prescribers and pharmacy benefit managers submitting PA requests for members needing these medications.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior Authorization Request Form — Overactive Bladder Agents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via the PA form or CoverMyMeds and include diagnosis (ICD-10), documentation of trials/intolerance to formulary alternatives or contraindications, and dosing within guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

7required clinical items

844-403-1029fax submission

CoverMyMedsonline portal

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.

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met:

Primary diagnosis: Provider selects diagnosis of Overactive bladder or supplies other diagnosis with ICD-10 code.

chunk 5

Formulary alternatives tried or contraindicated: Either (A) patient has demonstrated failure of or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary alternatives (examples: oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique) OR (B) patient has a documented contraindication to the listed formulary alternatives.

chunk 5

Adverse reaction: Documented adverse reaction to OR reasonable expectation of adverse reaction to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of the listed formulary agents (e.g., oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique).

chunk 5

No formulary option or special condition: Patient has a clinical condition for which there is no listed formulary agent to treat the condition based on published guidelines or clinical literature.

chunk 5

Dosing within guidelines: Drug is prescribed within the manufacturer's published dosing guidelines or the dose falls within accepted compendia/current literature (e.g., package insert, AHFS, Micromedex, current accepted guidelines).

chunk 5

The form does not list explicit exclusions beyond the clinical checklist items; instead, coverage is contingent on documenting the required clinical information. Providers must indicate the diagnosis (Overactive bladder or other with ICD-10 code), whether the patient has failed or is intolerant to a majority of preferred formulary alternatives (defined as two or more in a class with at least two alternatives or one in a class with only one alternative), any documented contraindications, adverse reactions to the listed agents, whether no formulary option exists for the patient’s clinical condition, and that the prescribed dosing is within manufacturer or accepted compendia guidelines.

Submitters should note that requests may be denied unless all required information is received. The form explicitly warns that incomplete submissions risk denial and asks providers to include all relevant supporting details and comments to avoid delays in review.

Diagnosis & Coding

Diagnosis codes requestedICD-10

ICD-10

Field for ICD-10 code for diagnosis (provider to supply specific code)

Formulary alternatives trial requirement summary

Majority-of-formulary-alternatives ruleDefined as failure of or intolerance to two or more agents in a therapeutic class when the class has at least two formulary alternatives, or failure/intolerance to the single available alternative when the class has only one formulary alternative.

Examples of agents counted toward the majorityoxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique.

Documentation requiredProvider must indicate on the PA form that the patient has demonstrated failure of or intolerance to the required majority of preferred formulary alternatives (Yes/No checklist).

Alternate pathwayIf the patient has a documented contraindication to the listed formulary alternatives, that may satisfy the formulary alternative requirement instead of documented failures.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: A prior authorization (PA) is required for this medication. Submit the completed PA using the Detrol/Overactive Bladder Prior Authorization Request Form or via CoverMyMeds. The form may be faxed to 844-403-1029.

Fax: 844-403-1029
Submission pathways: completed PA form or CoverMyMeds
Questions: contact prior authorization at 855-811-2218 (Monday–Friday, 8 a.m. to ?)

Step Therapy

Formulary Alternatives Trial Required

Formulary Alternatives: Provider must document failure of or intolerance to a majority of preferred formulary alternatives (two or more in a class with at least two alternatives, or one in a class with only one alternative) for the requested diagnosis, or document a contraindication or adverse reaction to the listed formulary agents.

Examples of preferred alternatives to document trial/failure: oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique

Initial Therapy Requirements

Initial therapy requirements

Initial coverage requires documentation of prior trials or contraindications and dosing within guidelines.

Diagnosis of overactive bladder with ICD-10 code provided on the form.

chunk 5

Formulary trial requirement: Failure of or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary alternatives OR documented contraindication to those alternatives (examples include oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique).

chunk 5

Adverse reaction consideration: If applicable, document adverse reaction to or reasonable expectation of adverse reaction to a majority of listed formulary agents.

chunk 5

Step Therapy / Trial Documentation

Form field / question	Provider response (as on form)
1. Select the diagnosis (check one) — Overactive bladder or Other (ICD-10 code required)	Checkbox: Yes / No (provider to supply ICD-10 code if Other)
2. Failure or intolerance to a majority of preferred formulary alternatives (examples listed: oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique)	Checkbox: Yes / No (document trials/failures on PA form)
3. Documented contraindication to the listed formulary alternatives (e.g., oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique)	Checkbox: Yes / No (provider documents contraindication on form)
4. Adverse reaction or reasonable expectation of adverse reaction to a majority of listed formulary agents	Checkbox: Yes / No (provider documents adverse reactions on form)
5. Clinical condition with no listed formulary agent based on published guidelines or literature	Checkbox: Yes / No (provider to describe condition if Yes)
6. Prescribed dosing within manufacturer's published dosing guidelines or accepted compendia/current literature	Checkbox: Yes / No (provider confirms dosing is within guidelines)
Prescriber's signature and date	Signature line / Date field (required)

Definitions

Definition — "failure of or intolerance to a majority of preferred formulary alternatives"

Definition"Failure of or intolerance to a majority of preferred formulary alternatives" means failure of or intolerance to two or more agents in a class when the class contains at least two formulary alternatives, or failure/intolerance to the single available alternative when a class has only one formulary option.

Checklist implementationThe PA form asks: "Has the patient demonstrated a failure of or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of the preferred formulary/preferred drug list alternatives for the given diagnosis?" (Yes/No).

Agent examples provided in formForm lists examples to illustrate the criterion: oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique.

Background

This prior authorization form is used to request coverage for medications indicated for overactive bladder. It lists commonly used antimuscarinic and related agents (examples on the form include oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, solifenacin, Gelnique) and captures whether the patient has failed or is intolerant to preferred formulary alternatives, has contraindications or adverse reactions to those agents, whether no formulary option exists for the patient’s condition, and confirmation that the prescribed dosing falls within manufacturer or accepted compendia guidelines.