Medicare AdvantagePrior AuthMedium impact
Lotronex® (alosetron HCl) (Revised)
Humana·Gastroenterology, Internal Medicine, Family Medicine·Medicare Advantage
Effective date
Feb 28, 2024
We identified it
Jun 25, 2026
Summary
Humana has revised its Lotronex (alosetron HCl) prior authorization policy effective February 28, 2024. This is a pharmacy coverage policy for Medicare Advantage and Commercial plans requiring prior authorization for Lotronex use in severe diarrhea-predominant IBS (IBS-D). The policy mandates that patients meet three strict criteria: diagnosis of severe IBS-D, chronic symptoms lasting 6+ months, and prior treatment failure or intolerance to both an antidiarrheal agent and a tricyclic antidepressant. Approval duration is for the initial plan year.
Action Required
By March 15, 2024: Billing and prior authorization teams must update internal protocols to reflect this revised Lotronex policy. (1) Verify all Lotronex prior authorization requests submitted after February 28, 2024 are evaluated against the three mandatory criteria: severe IBS-D diagnosis, 6+ months chronic symptoms, and documented failure/intolerance to one antidiarrheal agent (e.g., loperamide) AND one tricyclic antidepressant (e.g., amitriptyline, nortriptyline, imipramine HCl, desipramine). (2) Update prior authorization templates and clinical review guidelines in your PA system to include these specific requirements. (3) Communicate to prescribers that prior auth approval duration is limited to the initial plan year only—renewals will require new submissions. (4) Flag any pending requests for Lotronex that were submitted before this revision date and re-evaluate against current criteria. (5) Note the BLACK BOX WARNING: medication carries serious GI risk (ischemic colitis, constipation complications). Do not approve for patients with history of chronic/severe constipation, intestinal obstruction, ischemic colitis, Crohn's disease, ulcerative colitis, or those on concomitant fluvoxamine. Claims approved without meeting all three criteria or without contraindication screening may be subject to denial or recoupment. Reference Humana's TAD system (http://apps.humana.com/tad/tad_new/home.aspx) to confirm this remains the current policy version.