CurrentCignaPolicy IP0268

Colchicine oral solution (Gloperba) for gout flare prophylaxis

This Cigna Coverage Policy governs medical necessity review and coverage requirements for Gloperba (colchicine oral solution) used for prophylaxis of gout flares in adults under applicable Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyColchicine oral solution (Gloperba) for gout flare prophylaxis

Policy CodePolicy IP0268

Change TypeNo material clinical or coverage changes in this revision.

Effective DateNov 1, 2023

Next Review DateNov 1, 2024

Key ActionObtain prior authorization with documentation of age and preferred-alternative criteria; approvals may be granted for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+min age

up to 12 moauth duration

prophylaxis onlyindication

alternatives requiredpreferred products

Coverage Criteria for Gloperba (colchicine oral solution)

Policy Summary

PayerCigna

PolicyColchicine oral solution (Gloperba) for gout flare prophylaxis

Policy CodePolicy IP0268

Change TypeNo material clinical or coverage changes in this revision.

Effective DateNov 1, 2023

Next Review DateNov 1, 2024

Key ActionObtain prior authorization with documentation of age and preferred-alternative criteria; approvals may be granted for up to 12 months.

SourceLink

On This Page

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Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Medical necessity must meet age and alternative-preference criteria. Approvals may be granted for up to 12 months.

Effective Date: 2023-11-01
Policy Number: IP0268

Step Therapy

Preferred Product / Step Therapy

Use of preferred colchicine products is required when coverage is available. Coverage is limited to individuals who cannot swallow colchicine capsules/tablets OR who have documented inadequate response or intolerance to the preferred colchicine capsule or tablet.

Preferred alternatives: colchicine capsule or colchicine tablet
Limitations vary by customer benefit plan

Documentation Required

Required Documentation and Denial Triggers

Document the reason for coverage: either inability to swallow colchicine capsule/tablet OR documentation of inadequate response or intolerance to EITHER colchicine capsule or colchicine tablet. For reauthorization, document beneficial response and that initial criteria remain met. Lack of required documentation or failure to meet criteria may result in denial.

Document: age (>=18) and one of: inability to swallow capsules/tablets OR inadequate response/intolerance to capsule or tablet
Reauthorization: documentation of beneficial response
Denial triggers: missing documentation, not meeting age or alternative-preference criteria, or use for unproven indications

OpenPayer

Colchicine oral solution (Gloperba) for gout flare prophylaxis

Coverage Criteria for Gloperba (colchicine oral solution)

Provider Actions, Prior Authorization, and Documentation Requirements

Background

Definitions