Antihyperuricemics prior authorization (PA) for Georgia Medicaid
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Defines prior authorization criteria, quantity limits, and coverage guidance for antihyperuricemic agents (e.g., allopurinol, colchicine, febuxostat, probenecid, Gloperba) for Georgia Medicaid Fee-for-Service members and participating providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Antihyperuricemics
Gloperba (colchicine oral solution) approval
Gloperba is approvable when ALL of the following are met:
Age requirement from policy.
Indication requirement from policy.
Initiation on urate-lowering therapy required.
OR logic preserved for inability to use solids versus dosing not achievable with preferred products.
QLL override for colchicine products
Authorization to exceed Quantity Level Limit (QLL) may be approved when ANY of the following diagnoses are present:
Used to approve requests to exceed colchicine QLL.
Alternative diagnosis that may justify exceeding the QLL.
The policy specifies that no additional diagnoses beyond those listed are acceptable reasons to approve requests to exceed the colchicine Quantity Level Limit (QLL). The only diagnoses identified for QLL override are gout or gout flare when a member is being initiated on antihyperuricemic (urate‑lowering) therapy and Familial Mediterranean Fever (FMF); requests for other indications are not included as criteria for exceeding the colchicine QLL.
The policy lists preferred colchicine products (generic colchicine tablets and Mitigare capsules) and identifies Gloperba (colchicine oral solution) as a non‑preferred product. While the document requires prior authorization and step requirements for Gloperba, it does not explicitly label any other uses or products as “not medically necessary.”
Initial Therapy — Gloperba
Initial therapy — Gloperba
Covered when ALL of the following are met:
Supports approval for initiation phase to prevent gout flares; ties to Gloperba approval node.
Step Therapy and Preferred Product Requirements
| Step | Required prior step | Coverage action |
|---|---|---|
| 1 | ||
| Preferred products: generic colchicine tablets or Mitigare (colchicine capsules) | ||
| Member must try and fail or be unable to use preferred solid oral colchicine products before Gloperba (colchicine oral solution) is approved; approval may be granted if member is ≥18, is being initiated on urate‑lowering therapy, and cannot swallow solid oral dosage forms or requires dosing not achievable with preferred products. |
Quantity Limits for Colchicine Products
What Providers Must Do
PA required for non‑preferred products and QLL overrides
Prior authorization is required for non‑preferred colchicine products (for example, Gloperba) and for requests to exceed the Quantity Level Limit (QLL) for colchicine tablets/capsules. Providers must obtain authorization through the OptumRx prior authorization process before coverage will be approved for these situations.
Step therapy — use preferred colchicine formulations first
Use preferred colchicine products (generic colchicine tablets or Mitigare) before Gloperba; Gloperba (non‑preferred oral solution) is approvable only for members ≥18 who are initiating urate‑lowering therapy and cannot swallow solid oral dosage forms or require dosing not achievable with preferred products.
How to request PA or exceptions
Prior authorization requests and requests for exceptions are processed through OptumRx. Providers may initiate the PA process by calling the OptumRx prior authorization phone number.
- Call OptumRx at 1-866-525-5827 to initiate a PA or exception request.
Triggers for potential denial — age, indication, and QLL limits
Coverage for Gloperba is restricted to members 18 years of age or older and limited to gout prophylaxis when initiating antihyperuricemic therapy; requests outside those criteria or requests to exceed the colchicine QLL without an approved diagnosis (gout at initiation or FMF) may be denied.
- Gloperba approvals require member age ≥18 and diagnosis of gout for prophylaxis when initiating urate‑lowering therapy and inability to use solid oral forms or need for dosing not achievable with preferred products.
- Authorization to exceed the 40 tablets/capsules per 30 days QLL is only approved for gout/gout flare at initiation of urate‑lowering therapy or Familial Mediterranean Fever (FMF).
Definitions and Key Terms
Coding and Billing Notes
Preferred products relevant for coding and prior authorization decisions are generic colchicine tablets and Mitigare (colchicine capsules). The policy lists Gloperba (colchicine oral solution) as the non‑preferred product. The colchicine tablets and Mitigare are subject to a Quantity Level Limit of 40 tablets/capsules per 30 days.
Background
This policy covers urate‑lowering agents and medications used for gout‑flare prophylaxis, including xanthine oxidase inhibitors (for example, allopurinol and febuxostat), uricosurics (for example, probenecid), and colchicine formulations. It specifies product placement (preferred vs non‑preferred), prior authorization and step requirements for non‑preferred products such as Gloperba, and quantity limits for colchicine products. Gloperba is approvable for members aged 18 years or older for gout prophylaxis when the member is initiating urate‑lowering therapy and cannot use solid oral formulations or requires dosing not achievable with preferred products.
Revision History
Antihyperuricemics prior authorization policy published defining coverage and PA criteria for colchicine products, including Gloperba and Quantity Level Limits for colchicine tablets and Mitigare.
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