WHA

Overactive Bladder Agents

Indications for Prior Authorization

Gelnique (oxybutynin chloride)
  • For diagnosis of Overactive Bladder Symptoms
    Indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency.

Criteria

Gelnique

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]
    • Myrbetriq tablets
    • generic darifenacin ER
    • generic oxybutynin immediate-release (IR)/extended-release (ER)
    • generic solifenacin
    • generic tolterodine IR/ER
    • generic trospium IR/ER
    • generic fesoterodine ER

  • Guideline ID
    GL-143233

  • Formulary
    EHB

  • Effective date
    May 1, 2024

  • P&T approval date
    Mar 20, 2019

P & T Revisions

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

  1. Gelnique prescribing information. Allergan USA, Inc. Madison. NJ. March 2019.
  2. American Urological Association. Guideline on Diagnosis and Treatment of Non-Neurogenic Overactive Bladder (OAB) in Adults (2019). https://www.auanet.org/guidelines/overactive-bladder-(oab)-guideline. Accessed February 14, 2022.
  • 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.