Oncology - Mercaptopurine Products Step Therapy Policy
Defines step therapy requirements for mercaptopurine products (generic tablets, suspensions, and Purixan) for Cigna-administered health benefit plans; applies to providers requesting coverage for these products.
No material clinical or coverage changes in this revision.
Coverage Criteria
COVERAGE CRITERIA
Products are covered as medically necessary when the step therapy criteria below are met. Any other exception is considered not medically necessary.
General coverage
- Permissive conditions for Step 2 without Step 1: Approve a Step 2 product if the patient has tried one Step 1 product OR if the patient cannot swallow or has difficulty swallowing tablets.1 of 2
These two conditions are alternative pathways to approve Step 2
Step sequencing defined in policy statement
Products are covered as medically necessary only when the step therapy criteria are met. This policy requires use of a Step 1 product (generic mercaptopurine tablets) prior to a Step 2 product (Purixan suspension or generic mercaptopurine suspension). If the Step Therapy rule is not met for a Step 2 product at the point of service, coverage will be determined by the step therapy criteria. All approvals are provided for 1 year in duration. Any use that does not meet these step therapy criteria is considered not medically necessary.
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