CurrentNeighborhood Health Plan of Rhode IslandPolicy Viberzi Pa Policy 1271 A 1287 A 10 2022
Viberzi Pa Policy 1271 A 1287 A 10 2022
Defines prior authorization criteria for coverage of Viberzi (eluxadoline) for treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults under CVS Caremark criteria as used by Neighborhood Health Plan of Rhode Island.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyViberzi Pa Policy 1271 A 1287 A 10 2022
Policy CodePolicy Viberzi Pa Policy 1271 A 1287 A 10 2022
Change TypeNo material change
Effective Date
Next Review Date
Key ActionCoverage requires prior authorization consistent with CVS Caremark criteria and documentation that the patient is an adult with IBS-D and does not have any listed contraindications.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes.
1Indication covered
6Contraindications/exclusions listed
Coverage Summary
Coverage stance: covered_with_criteria. This policy follows CVS Caremark prior authorization criteria and covers Viberzi (eluxadoline) for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults when prior authorization criteria are met, including documentation of an adult IBS-D diagnosis and absence of listed contraindications.