Alosetron Prior Authorization with Quantity Limit Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Alosetron will be approved when ALL of the following are met:

1. The patient has a diagnosis of irritable bowel syndrome with severe diarrhea (IBS-D) AND 
2. The patient’s sex is female AND 
3. The patient exhibits at least ONE of the following
   1. Frequent and severe abdominal pain/discomfort OR 
   2. Frequent bowel urgency or fecal incontinence OR 
   3. Disability or restriction of daily activities due to IBS AND 
4. The prescriber has ruled out anatomic or biochemical abnormalities of the gastrointestinal tract AND 
5. The patient does NOT have any FDA labeled contraindications to the requested medication AND 
6. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. ALL of the following: 
      1. The requested quantity (dose) is greater than the program quantity limit AND 
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit AND 
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication 

Length of Approval: 12 months