Pharmacy Prior Authorization Criteria

Elmiron (pentosan polysulfate sodium) - PA, NF

Indications for Prior Authorization

Elmiron (pentosan polysulfate sodium)

• For diagnosis of Interstitial Cystitis
  Indicated for the relief of bladder pain or discomfort associated with interstitial cystitis.

Criteria

Elmiron

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of interstitial cystitis
AND
• Patient has bladder pain or discomfort
AND
• Trial and failure (of a minimum 30 days supply), contraindication, or intolerance to two of the following: [2]
• Amitriptyline
• Cimetidine
• Hydroxyzine

Elmiron

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

Elmiron

Non Formulary

Length of Approval: 6 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of interstitial cystitis
AND
• Patient has bladder pain or discomfort
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming trial and failure (of a minimum 30 days supply), contraindication, or intolerance to two of the following: [2]
• Amitriptyline
• Cimetidine
• Hydroxyzine

P & T Revisions

2026-01-04, 2025-12-18, 2025-12-18, 2021-09-15, 2021-04-06

References

1. Elmiron Prescribing Information. Janssen Pharmaceuticals, Inc. Titusville, NJ. June 2020.
2. American Urological Association. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (2022). Available at: https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-treatment-interstitial-of-cystitis/bladder-pain-syndrome-(2022). Accessed January 1, 2026.
3. UptoDate. Interstitial cystitis/bladder pain syndrome: Management. Available at: https://www.uptodate.com/contents/interstitial-cystitis-bladder-pain-syndrome-management?search=interstitial%20cystitis%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed January 1, 2026.

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Revision History

• 2026-01-04: 2026 Annual Review.
• 2025-12-18: No criteria change, bulk copy oRX-EHB
• 2025-12-18: no criteria changes, added IL statute operational note
• 2021-09-15: Addition of EHB Formulary to guideline
• 2021-04-06: New program

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