Glycopyrrolate oral products — coverage criteria
Cigna coverage policy governing medical necessity and authorization for specific oral glycopyrrolate products (Dartisla ODT, glycopyrrolate 1.5 mg tablet, Robinul, Robinul Forte) as adjunct therapy for peptic ulcer disease in adults, including reauthorization and duration guidance.
No material clinical or coverage changes in this revision.
Coverage Criteria
Product-specific initial therapy criteria
Covered when ALL of the following are met for each specific product:
A. Age 18 years or older; B. Documentation of an inability to swallow glycopyrrolate 2 mg tablets.
A. Age 18 years or older; B. Documentation of failure, contraindication, or intolerance to ONE of the following: i. glycopyrrolate 1 mg tablet.
A. Age 18 years or older; B. Documented trial of glycopyrrolate 1 mg tablet (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s).
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.