Viberzi Prior Authorization with Quantity Limit Criteria - Medicare Part D

Prior Authorization Criteria for Approval

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

1. The patient has a diagnosis of irritable bowel syndrome with diarrhea (IBS-D)
   AND
2. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
3. 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