CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Mirabegron (formulary coverage) — Coverage Criteria

Defines prior authorization, step therapy, quantity limits, and coverage duration for mirabegron for members; applies to pharmacy benefit for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMirabegron (formulary coverage) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization documenting trial and inadequate response or intolerance to an antimuscarinic agent for coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration per approval

25 mg, 50 mgavailable strengths

1/dayquantity limit

365 daysstep therapy lookback

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met

Prior therapy: Member has trialed and experienced an inadequate treatment response or intolerance to an antimuscarinic drug (e.g., darifenacin, oxybutynin, solifenacin, trospium, tolterodine)trial documented

Examples of acceptable antimuscarinics are listed

Quantity limit: Limit to 1 tablet per day for 25 mg and 50 mg strengths1 tablet/day

Approval duration: Coverage duration is 12 months12 months

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMirabegron (formulary coverage) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization documenting trial and inadequate response or intolerance to an antimuscarinic agent for coverage.

SourceLink

On This Page

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.

Use of mirabegron for investigational indications or at doses or for conditions not recognized as medically accepted is not covered. Therapies are considered investigational when used at a dose or for a condition other than those recognized as medically accepted indications in standard reference compendia or peer-reviewed literature.

Formulations, Codes & Step Therapy Lookback

Formulations/StrengthsNDC | mixedCovered

25mg	tablet strength
50mg	tablet strength

Step therapy lookback — 365 days

Step therapy lookback365 days

Related requirementMember must have at least one paid claim for a formulary antimuscarinic or Myrbetriq within the prior 365 days

PurposeUsed by step-therapy coding logic to determine prior exposure to antimuscarinic agents

Prior Authorization & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to an antimuscarinic agent (examples: darifenacin, oxybutynin, solifenacin, trospium, tolterodine). Approval duration is 12 months. Quantity limit: 25 mg and 50 mg — 1 tablet per day.

Required medical information: Documentation of trial and inadequate response or intolerance to an antimuscarinic (e.g., darifenacin, oxybutynin, solifenacin, trospium, tolterodine).
Coverage duration: 12 months.
Quantity limit: 25 mg & 50 mg — 1 tablet per day.

Step Therapy

Step Therapy Coding Logic

Step therapy will adjudicate mirabegron (Myrbetriq) as meeting the step requirement when there is evidence of at least one paid claim within the prior 365 days for a formulary antimuscarinic agent.

Step therapy coding logic: paid claim within last 365 days for any of: darifenacin, oxybutynin, solifenacin, trospium, tolterodine, or Myrbetriq.
Operational note: a paid claim for a formulary antimuscarinic within 365 days satisfies the step requirement; otherwise documentation of trial and inadequate response or intolerance must be provided.

Documentation Required

Documentation Requirements

Documentation must include the specific antimuscarinic tried, dates of therapy, and reason for inadequate response or intolerance.

Examples of required medical information: agent name (darifenacin, oxybutynin, solifenacin, trospium, tolterodine), dates of trial, and clinical rationale for failure or intolerance.
Failure to document a trial and inadequate response or intolerance to an antimuscarinic will result in denial of coverage.

Background

Mirabegron is indicated for overactive bladder and is used as an alternative to antimuscarinic agents when those agents are ineffective or not tolerated. Prior authorization requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to an antimuscarinic agent (examples include darifenacin, oxybutynin, solifenacin, trospium, tolterodine).

For coverage purposes, the policy specifies a 12‑month approval duration and a quantity limit of 1 tablet per day for the 25 mg and 50 mg tablet strengths. Step‑therapy coding logic allows mirabegron to adjudicate if there is at least one paid claim within the prior 365 days for formulary darifenacin, oxybutynin, solifenacin, trospium, tolterodine, or Myrbetriq.

Definitions / Examples

Antimuscarinic agents (examples)

Antimuscarinic examplesdarifenacin

Antimuscarinic examplesoxybutynin

Antimuscarinic examplessolifenacin

Antimuscarinic examplestrospium

Antimuscarinic examplestolterodine

Initial Therapy Criteria

Initial therapy requirements

Initial therapy: Trial and inadequate response or intolerance to an antimuscarinic agent required prior to mirabegron coveragedocumented trial

Examples listed

Continuation / Renewal Criteria

Continuation therapy

Renewal/continuation

Continuation: Coverage may be renewed for 12 months provided ongoing clinical benefit and no intolerance; prior therapy requirement remains applicable for initial approval12 months

Step Therapy Rules

Requirement	Details
Step-therapy lookback period	At least one paid claim within the last 365 days
Required prior agents (formulary)	Darifenacin, oxybutynin, solifenacin, trospium, tolterodine, or Myrbetriq
Clinical requirement	Trial and documented inadequate response or intolerance to an antimuscarinic agent
Coverage action when requirement met	Mirabegron will adjudicate/pay when at least one paid claim for a listed agent is present within the prior 365 days

Quantity Limits

Mirabegron 25 mg & 50 mg tablets — quantity limit 1

Quantity limit1 tablet per day

Applicable strengths25 mg tablet

Applicable strengths50 mg tablet