CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Mirabegron (Myrbetriq) — Coverage and Prior Authorization Criteria

Coverage and prior authorization requirements for the drug mirabegron (Myrbetriq) for treatment of overactive bladder in members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMirabegron (Myrbetriq) — Coverage and Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeMinor review — no material changes

Effective DateN/A

Next Review DateApr 1, 2025

Key ActionObtain prior authorization documenting trial and inadequate response or intolerance to at least one antimuscarinic and evidence of a formulary claim within the last 365 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthscoverage duration

25 mg, 50 mgtablet strengths

1required antimuscarinic trials

365 dayslookback

Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial therapy criteria: Member has trialed and experienced an inadequate treatment response or intolerance to an antimuscarinic drug (e.g., darifenacin, oxybutynin, solifenacin, trospium, tolterodine).at least 1 prior antimuscarinic trial

Evidence may include a formulary claim within the last 365 days.

Claims evidence: At least one claim within the last 365 days for a formulary antimuscarinic or prior Myrbetriq paid days to support step requirement.>=1 claim in 365 days

Supports step therapy logic.

Coverage Duration

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMirabegron (Myrbetriq) — Coverage and Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeMinor review — no material changes

Effective DateN/A

Next Review DateApr 1, 2025

Key ActionObtain prior authorization documenting trial and inadequate response or intolerance to at least one antimuscarinic and evidence of a formulary claim within the last 365 days.

SourceLink

On This Page

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Approval duration: Coverage duration: 12 months.12 months

Standard coverage period per policy.

Coverage for mirabegron is restricted to medically accepted uses. Neighborhood Health Plan of Rhode Island considers therapies investigational and not covered when they are used at a dose or for a condition that is not recognized as a medically accepted indication in one of the standard compendia. Accepted references include AHFS‑DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs, or peer‑reviewed published medical literature demonstrating sufficient evidence to support the use. If the requested use (dose or condition) is not supported by these sources, coverage may be denied as investigational.

Coding & Claims

No codes listedmixed

No codes listed

Formulary claim lookback

Lookback periodAt least one claim within the last 365 days

Applies toFormulary antimuscarinics (darifenacin, oxybutynin, solifenacin, trospium, tolterodine) or prior Myrbetriq paid days

PurposeSatisfies step therapy requirement for mirabegron coverage

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approval is contingent upon documentation showing the member has trialed and experienced an inadequate treatment response or intolerance to at least one antimuscarinic agent (e.g., darifenacin, oxybutynin, solifenacin, trospium, tolterodine).

Required documentation: evidence of trial and inadequate response or intolerance to ≥1 antimuscarinic.
Coverage duration: 12 months when criteria met.

Step Therapy

Step therapy applies. Mirabegron (Myrbetriq) will be approved if there is at least one paid claim within the last 365 days for a formulary antimuscarinic (darifenacin, oxybutynin, solifenacin, trospium, tolterodine).

Lookback period: 365 days.
Acceptable agents: darifenacin, oxybutynin, solifenacin, trospium, tolterodine.

Documentation Required

Required Documentation

Documentation must include clinical evidence that the member trialed and had an inadequate response to or intolerance of at least one antimuscarinic agent. Acceptable documentation includes prior pharmacy claims, provider notes, or documentation of adverse effects leading to discontinuation.

Acceptable evidence: pharmacy claim history, chart notes, or medication trial documentation.
Specify agent tried and reason for failure or intolerance.

Denial Risk

Investigational Use — Denial Risk

Investigational use is not covered. Therapies are considered investigational when used at a dose or for an indication not recognized as medically accepted per standard compendia (AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Lexi‑Drugs) or supported only by insufficient peer‑reviewed evidence.

Not covered when used for investigational purposes or for non‑approved indications/doses.
Reference compendia: AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs.

Background

Mirabegron (Myrbetriq) is a beta‑3 adrenergic agonist used for the treatment of overactive bladder and is typically considered after trial or intolerance to antimuscarinic agents. For prior authorization, the policy requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to at least one antimuscarinic (examples: darifenacin, oxybutynin, solifenacin, trospium, tolterodine). Step therapy is satisfied when there is at least one formulary antimuscarinic claim within the last 365 days or evidence of prior Myrbetriq paid days.

Definitions

Investigational use definition

DefinitionUse at a dose or for a condition other than those recognized as medically accepted indications per standard compendia (AHFS-DI, DrugDex, Clinical Pharmacology, Lexi-Drugs, or peer-reviewed literature).

Coverage stanceNeighborhood does not provide coverage when used for investigational purposes

ReferencesStandard compendia: AHFS-DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, or peer-reviewed literature

Initial Therapy Criteria

Initial Therapy

Initial approval: Member must have trialed and had inadequate response or intolerance to at least one antimuscarinic (darifenacin, oxybutynin, solifenacin, trospium, tolterodine).>=1 failed/intolerant antimuscarinic

Step satisfied by a formulary claim within 365 days or prior Myrbetriq paid days.

Continuation / Renewal Criteria

Continuation Therapy

Continuation/renewal

Renewals should document ongoing clinical benefit and adherence; coverage duration set to 12 months per approval.12 months

Document that prior response/intolerance history was present at initial authorization.

Step Therapy Requirements

Step	Requirement
1	At least one claim for a formulary antimuscarinic (darifenacin, oxybutynin, solifenacin, trospium, tolterodine) within the last 365 days or prior Myrbetriq paid days.

Quantity Limits

mirabegron — quantity limit

DrugMirabegron (Myrbetriq)

Quantity limit1 tablet per day

Tablet strengths25 mg, 50 mg