Subject: Viberzi PA 1287-A, 1271-A P10-2025
Policy:
Indications
FDA-approved Indications
Viberzi is indicated in adults for the treatment of irritable bowel syndrome with diarrhea (IBS-D).
Coverage Criteria
Irritable Bowel Syndrome with Diarrhea (IBS-D)
Authorization may be granted when the requested drug is being prescribed for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in an adult patient when the following criteria is met:
- The patient does NOT have ANY of the following:
- A history of cholecystectomy
- A history of chronic or severe constipation or sequelae from constipation, or known or suspected mechanical gastrointestinal obstruction
- Known or suspected biliary duct obstruction or sphincter of Oddi disease or dysfunction
- A history of pancreatitis or structural diseases of the pancreas, including known or suspected pancreatic duct obstruction
- Severe hepatic impairment (Child-Pugh Class C)
- Alcoholism, alcohol abuse or alcohol addiction, or a patient who drinks more than 3 alcoholic beverages per day
Duration of Approval (DOA)
- 1287-A: DOA: 36 months
- 1271-A: DOA: 12 months
Place of Service:
Outpatient
The above policy is based on the following references:
- Viberzi [package insert]. Madison, NJ: Allergan USA, Inc; July 2016.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2025. https://online.lexi.com. Accessed September 15, 2025.
- Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 09/15/2025).
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
February 14, 2026
