CurrentMass General Brigham Health PlanPolicy N/A

Febuxostat (Uloric) coverage

Defines prior authorization, step therapy, and quantity limits for febuxostat prescriptions under the pharmacy benefit for Mass General Brigham Health Plan members, affecting prescribers and pharmacy staff processing claims.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFebuxostat (Uloric) coverage

Policy CodePolicy N/A

Change TypeMaterial revision — clarified new-to-plan continuity and PA criteria

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit a prior authorization for febuxostat when the member does not meet step‑therapy requirements or to continue therapy for new‑to‑plan members receiving the medication within the past 90 days.

SourceLink

POLICY UPDATE CHANGES

Updated PA criteria to include that members new to the plan who are currently on the second‑line medication may be authorized.

Updated criteria to require that the member is currently on the second‑line medication for new‑to‑plan continuity approvals.

30Quantity limit (8 mg/40 mg)

180Look-back period (days)

90New-to-plan window (days)

Coverage Criteria for Febuxostat

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Initial Therapy — Covered when ANY of the following are met:

Covered when ANY of the following are met:

New-to-plan continuity: Member is currently receiving the requested medication and is new to the plan within the past 90 days (excluding products obtained as samples or via manufacturer's patient assistance programs).new-to-plan <=90 days

Supports continuity of therapy

Recent fill of first- or second-line agent: Member has filled a first-line medication (allopurinol) or a second-line medication (febuxostat) within the past 180 days, allowing second-line adjudication at point of sale.lookback <=180 days

Automatic adjudication at point of sale when satisfied

Failure/intolerance to first-line: Member has had an inadequate response, adverse reaction, or contraindication to a first-line medication (allopurinol).clinical

Requires documentation in the prior authorization request

Febuxostat is not recommended for the treatment of asymptomatic hyperuricemia. This agent is indicated for management of hyperuricemia in adult patients with gout only when there is an inadequate response to a maximally titrated dose of allopurinol, intolerance to allopurinol, or when allopurinol is not advisable. Prescriptions that do not meet initial step‑therapy requirements at the point of sale will require prior authorization and may be denied without an approved PA.

Initial Therapy Rules

Initial therapy rules — Initial coverage and step therapy

Initial coverage and step therapy

First-line failure or intolerance: Inadequate response, adverse reaction, or contraindication to allopurinol.clinical

PA documentation required

Recent fill for step therapy: Member has filled allopurinol or febuxostat within the past 180 days to qualify for febuxostat adjudication at point of sale.<=180 days

Automated at POS when satisfied

Step	Requirement	Coverage action
1
Member must have filled a first-line medication (allopurinol) or a second-line medication within the past 180 days, or meet prior authorization criteria (including new-to-plan continuity when applicable)
Febuxostat will adjudicate without prior authorization when the step requirement is met at point of sale; otherwise prior authorization is required

Continuation Therapy

Continuation therapy — Continuity for members new to the plan

Continuity for members new to the plan

New-to-plan continuity: Member is new to the plan within the past 90 days AND is currently receiving the requested febuxostat (not obtained as samples or via manufacturer's patient assistance programs).new-to-plan <=90 days

Allows authorization to continue existing therapy

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required when step‑therapy requirements are not met. Prescriptions that meet the initial step‑therapy requirements will adjudicate automatically at point of sale. If the prescription does not meet the initial step‑therapy requirements, the claim will require prior authorization and will be denied at point of sale until a PA is submitted and approved.

Prescriptions that meet initial step therapy adjudicate at point of sale
If initial step therapy not met, adjudication returns PA required / deny message

Step Therapy

Step‑Therapy Structure

First‑line medications (allopurinol) are covered without prior authorization. Febuxostat is designated a second‑line agent and will adjudicate only if the member has filled a first‑line or second‑line medication within the past 180 days. Providers should attempt first‑line therapy prior to prescribing second‑line agents unless an exception is documented.

First‑line: Allopurinol — no prior authorization required
Second‑line: Febuxostat tablet — requires evidence of a fill for a first‑line or second‑line agent within past 180 days

Documentation Required

Documentation for New‑to‑Plan Members and Clinical Criteria

For members new to the plan within the past 90 days, authorization may be granted if the member is currently receiving the requested medication (excludes samples and medications obtained via manufacturer patient assistance programs). For other requests, documentation must show that the member has had an inadequate response, adverse reaction, or contraindication to a first‑line medication (e.g., allopurinol) to support approval of a second‑line agent.

New‑to‑plan (≤ 90 days): can grant authorization if member currently receiving the requested drug (exclude samples/PAP)
Clinical criteria for second‑line approval: inadequate response, adverse reaction, or contraindication to a first‑line medication
Document prior fills and clinical rationale when submitting PA

Definitions

Second-line medication — definition

DefinitionSecond-line medication: an agent used when a first-line medication (allopurinol) produced inadequate response, adverse reaction, or is contraindicated.

Role in step therapyFebuxostat is designated as a second-line agent and requires prior authorization if step-therapy requirements are not met.

Documentation requirementClinical documentation must show inadequate response, intolerance, or contraindication to allopurinol to support use of a second-line agent.

Background

Febuxostat is a xanthine oxidase inhibitor indicated for management of hyperuricemia in adult patients with gout who have an inadequate response to a maximally titrated dose of allopurinol, are intolerant of allopurinol, or when allopurinol is not advisable. It is not recommended for asymptomatic hyperuricemia. Prescriptions that meet the initial step‑therapy requirements will adjudicate automatically at the point of sale; prescriptions that do not meet those requirements will require prior authorization.

Revision History and Policy Changes

2025-03-01Effective dateLatest

Policy retitled from 'Uloric' to 'febuxostat' to reflect generic availability and updated PA criteria to allow continuity for members new to the plan who are currently on the second-line medication.

2024-12-11Revision

Reviewed and updated at December P&T to add language allowing members new to the plan who are currently on the second-line medication to be considered for PA; noted policy title change to febuxostat with effective date 03/01/2025.

2020-03-18Revision

Reviewed and updated criteria to step-therapy (ST) with an effective date of 2020-06-01.

2018-11-26Review

Policy reviewed.

2014-11-24Review

Policy reviewed.

2013-11-25Review

Policy reviewed.

2012-12-01Update

Policy updated.

2012-11-26Review

Policy reviewed.

2011-11-28Update

Policy updated.

2010-11-22Approval

3-year approval granted.

2010-01-04Review

Policy reviewed.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFebuxostat (Uloric) coverage

Policy CodePolicy N/A

Change TypeMaterial revision — clarified new-to-plan continuity and PA criteria

Effective DateMar 1, 2025

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Febuxostat (Uloric) coverage

Coverage Criteria for Febuxostat

Initial Therapy Rules

Continuation Therapy

Provider Actions and Prior Authorization

Definitions

Background

Quantity Limits

Revision History and Policy Changes