Pharmacy Prior Authorization Criteria

Elmiron (pentosan polysulfate sodium)

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)

• Documentation of positive clinical response to therapy

P & T Revisions

2021-09-15, 2021-04-06

References

1. Elmiron Prescribing Information. Janssen Pharmaceuticals, Inc. Titusville, NJ. June 2020.
2. Hanno PM, Erickson D, Moldwin R, et al. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol . 2015 May;193(5):1545-53. doi: 10.1016/j.juro.2015.01.086.

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Revision History

• 2021-09-15: Addition of EHB Formulary to guideline
• 2021-04-06: New program

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