Pharmacy Prior Authorization Criteria

Overactive Bladder Agents

For diagnosis of Overactive Bladder Symptoms
Indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency.

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to two of the following: [2]

2025-02-19, 2024-02-19, 2023-03-15, 2022-08-04, 2022-03-03, 2021-09-17, 2021-06-28, 2021-05-20, 2021-03-04, 2020-01-31, 2019-12-10, 2019-11-18

Gelnique prescribing information. Allergan USA, Inc. Madison. NJ. March 2019.
Cameron AP, Chung DE, Dielubanza EJ, et al. The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. J Urol. 2024;212(1):11-20. Available at: https://www.auajournals.org/doi/10.1097/JU.0000000000003985. Accessed January 29, 2025.

2025-02-19: 2025 Annual Review. No criteria changes. Updated References.
2024-02-19: 2024 Annual review. No changes to clinical criteria. Updated GPIs.
2023-03-15: Annual review - added FDA approved indication criterion.
2022-08-04: Updated ST to include generic fesoterodine as ST1 alt.
2022-03-03: Annual review - updated references.
2021-09-17: Criteria update to state Myrbetriq "tablets".
2021-06-28: Updated prerequisite options to include Myrbetriq, generic darifenacin ER and generic solifenacin.
2021-05-20: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
2021-03-04: Annual review - added "minimum 30-day supply" language to T/F requirement. Added trospium ER and tolterodine ER as additional T/F options. Updated references.
2020-01-31: Annual review - updated references.
2019-12-10: EHB guideline that only targets Gelnique.
2019-11-18: Removed Vesicare as target from existing guideline as it will be managed via the Generic-first Program.