CurrentUnitedHealthcarePolicy N/A

Step therapy for mirabegron (generic Myrbetriq)

This program governs prior authorization and step-therapy requirements for coverage of generic mirabegron for treatment of overactive bladder in adult UnitedHealthcare members; it requires trial of specified lower-cost alternatives before approval.

Policy Summary

PayerUnitedHealthcare

PolicyStep therapy for mirabegron (generic Myrbetriq)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization after documenting trial and failure (or contraindication/intolerance/inadequate response) of both oxybutynin and solifenacin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2required alternative agents before mirabegron approval

12 moauthorization duration

Myrbetriqbrand excluded

adult OABindication referenced

Coverage Criteria

Initial Therapy

Covered when ALL of the following are met

Step therapy requirements: Member has history of failure, contraindication, intolerance, or inadequate response to BOTH oxybutynin (generic Ditropan or Ditropan XL) and solifenacin (generic Vesicare)both agents

Mirabegron (generic) will be approved only after these requirements are satisfied

Authorization duration: Authorization will be issued for 12 months12 months

State mandates, federal regulatory requirements, and the member-specific benefit plan may further impact coverage

Brand Myrbetriq is typically excluded from coverage.

Policy Summary

PayerUnitedHealthcare

PolicyStep therapy for mirabegron (generic Myrbetriq)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization after documenting trial and failure (or contraindication/intolerance/inadequate response) of both oxybutynin and solifenacin.

SourceLink

On This Page

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Prior Authorization

Prior Authorization Required

Prior authorization is required for mirabegron (generic). Approval is contingent on documentation that the member has a history of failure, contraindication, intolerance, or inadequate response to both oxybutynin (generic Ditropan or Ditropan XL) and solifenacin (generic Vesicare). Authorization, when approved, will be issued for up to 12 months. Brand Myrbetriq is typically excluded from coverage. State mandates, federal regulatory requirements, and the member's specific benefit plan may affect coverage decisions.

Affected drug: mirabegron (generic)
Required prior trials: oxybutynin (generic Ditropan or Ditropan XL) AND solifenacin (generic Vesicare)
Approval duration: up to 12 months
Brand Myrbetriq: typically excluded

Documentation Required

Use of Claims and Diagnosis for Authorization

UnitedHealthcare may authorize initial approvals and reauthorizations based solely on claim/medication history, relevant ICD-10 diagnosis codes, and/or automated claim logic. Use of these automated approval and reapproval processes varies by program and therapeutic class. Providers should ensure claim histories and diagnosis coding accurately reflect prior trials, adverse reactions, or contraindications to support authorization.

Authorizations may be based on: claim/medication history, ICD-10 diagnosis codes, and/or automated claim logic
Automated approvals vary by program/therapeutic class
Ensure accurate documentation in claims to reflect prior trials, contraindications, or intolerances

Step Therapy

Step Therapy Requirements

Step therapy requirement: a trial and failure (or documented contraindication, intolerance, or inadequate response) of two alternatives (oxyb utynin and solifenacin) is required prior to coverage of mirabegron. Failure to document prior trials or relevant clinical reasons for bypass may result in denial or delay of authorization.

Step therapy alternatives: oxybutynin and solifenacin
Acceptable reasons to bypass step therapy: contraindication, intolerance, or inadequate response
Operational note: lack of documentation for prior trials may lead to denial or request for additional information

Documentation Required

Documentation and Operational Considerations

Operational note: If prior trials and failures (or documented contraindication/intolerance/inadequate response) to both oxybutynin and solifenacin are not documented, UnitedHealthcare may deny the request or require additional information. State mandates and the member's benefit plan may modify these operational requirements.

Insufficient documentation may result in denial or request for more information
State and plan-specific rules may override or modify requirements

Definitions

inv-08: OAB — Overactive bladder (OAB)

DefinitionOveractive bladder (OAB) — condition presenting with symptoms of urge urinary incontinence, urinary urgency, and urinary frequency in adults.

Typical patient populationAdults with symptoms of urge urinary incontinence, urgency, and urinary frequency.

Associated therapiesMay be treated with mirabegron (generic Myrbetriq) alone or in combination with solifenacin succinate.

Purpose of step therapyProgram requires trials of lower‑cost alternatives before mirabegron to encourage use of less costly agents.

Clinical context noteMirabegron is indicated for OAB and referenced as part of a step therapy program in this policy.

OpenPayer

Step therapy for mirabegron (generic Myrbetriq)

Coverage Criteria

Provider Actions & Authorization Requirements

Background

Definitions