CurrentCignaPolicy N/A

Overactive Bladder Medications Preferred Step Therapy Policy

Defines preferred step therapy requirements for coverage of overactive bladder (OAB) medications for Cigna-administered health benefit plans; affects prescribers and prior authorization reviewers for Cigna members.

Policy Summary

PayerCigna

PolicyOveractive Bladder Medications Preferred Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 21, 2025

Key ActionObtain trial of one Step 1 product before requesting approval for a Step 2 product; authorizations are granted for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2therapy steps

1 yearapproval duration

<3 yrspediatric exception

Nonerecent changes

Coverage Criteria for Overactive Bladder Medications

Preferred Step Therapy Criteria

Covered when ALL of the following are met

Step therapy prerequisites: Patient has tried one Step 1 product prior to approval of a Step 2 product.

Step 1 product list: generic darifenacin ER, generic fesoterodine ER, Gelnique, generic mirabegron ER, Myrbetriq, Myrbetriq Granules, generic oxybutynin IR, generic oxybutynin syrup, generic oxybutynin ER, generic solifenacin succinate, generic tolterodine tartrate (IR and ER), generic trospium (IR and ER). Step 2 product list: Detrol, Detrol LA, Ditropan XL, Enablex, Oxytrol (prescription), Oxytrol for Women (OTC), Toviaz, Vesicare, Vesicare LS.

Authorization duration: Approvals are provided for 1 year in duration.1 year

If Step 1 requirement is met, Step 2 product is covered as medically necessary.

Pediatric exception:

Policy Summary

PayerCigna

PolicyOveractive Bladder Medications Preferred Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 21, 2025

Key ActionObtain trial of one Step 1 product before requesting approval for a Step 2 product; authorizations are granted for 1 year.

SourceLink

On This Page

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Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required for Step 2 Products

Step therapy prior authorization is required for Step 2 products. Approvals are provided for 1 year in duration.

All approvals valid for 1 year

Step Therapy

Step Therapy Requirement

Coverage for Step 2 products will be determined by the Preferred Step Therapy criteria. If the Preferred Step Therapy rule is not met at the point of service, the Preferred Step Therapy criteria must be applied to determine medical necessity.

Step 2 coverage contingent on meeting Preferred Step Therapy criteria at point of service

Step Therapy

Preferred Step Therapy Rule

Preferred Step Therapy rule: patients must try one Step 1 product prior to approval of a Step 2 product. Step 1 and Step 2 product lists: Step 1 includes generic darifenacin ER, generic fesoterodine ER, Gelnique, generic mirabegron ER, Myrbetriq (including Granules), generic oxybutynin IR/syrup/ER, generic solifenacin, generic tolterodine IR/ER, generic trospium IR/ER. Step 2 includes Detrol, Detrol LA, Ditropan XL, Enablex, Oxytrol (prescription), Oxytrol for Women (OTC), Toviaz, Vesicare, Vesicare LS. If the patient has tried one Step 1 product, approve a Step 2 product. Exception: patients < 3 years of age — approve Vesicare LS.

Step 1 product list: generic darifenacin ER; generic fesoterodine fumarate ER; Gelnique; generic mirabegron ER; Myrbetriq; Myrbetriq Granules; generic oxybutynin IR; generic oxybutynin IR syrup; generic oxybutynin ER; generic solifenacin succinate; generic tolterodine tartrate; generic tolterodine ER; generic trospium chloride IR; generic trospium chloride ER
Step 2 product list: Detrol; Detrol LA; Ditropan XL; Enablex; Oxytrol (prescription); Oxytrol for Women (OTC); Toviaz; Vesicare; Vesicare LS
If patient has tried one Step 1 product, approve a Step 2 product
If patient is < 3 years of age, approve Vesicare LS

Documentation Required

Billing and Documentation Guidance

Billing and documentation: Providers must submit claims using the most appropriate diagnosis and procedure codes and include supporting documentation consistent with the applicable coverage policy. Claims for services not accompanied by covered code(s) under the policy will be denied as not covered.

Use current, appropriate diagnosis and procedure codes as of the date of service
Include supporting clinical documentation that demonstrates that preferred step therapy criteria are met or documents an approved exception

Definitions and Product Details

Myrbetriq (mirabegron)

Drug classBeta-3 adrenergic agonist

IndicationsTreatment of overactive bladder (OAB) symptoms — urge urinary incontinence, urgency, and frequency

Monotherapy/combinationIndicated for use as monotherapy or in combination with solifenacin

Guideline placementListed as a second-line therapy alongside oral antimuscarinics per AUA/SUFU guidance

Clinical noteAppears similar in efficacy to antimuscarinic agents; can be considered when antimuscarinics are ineffective or not tolerated

Oxytrol for Women (OTC)

ProductOxytrol for Women (OTC) — transdermal oxybutynin patch

IndicationIndicated for women ≥ 18 years for treatment of OAB symptoms (urge urinary incontinence, urgency, frequency)

Dose/formulationOTC and prescription Oxytrol contain the same dose of oxybutynin (3.9 mg/day)

Formulation noteTransdermal formulation may be used as an alternative for patients who experience dry mouth with oral antimuscarinics

Prescription vs OTCPrescription Oxytrol is indicated for men; OTC 'Oxytrol for Women' is indicated for women ≥18 years

OpenPayer

Overactive Bladder Medications Preferred Step Therapy Policy

Coverage Criteria for Overactive Bladder Medications

Provider Requirements and Prior Authorization

Background

Definitions and Product Details

Revision History