CurrentNeighborhood Health Plan of Rhode IslandPolicy 873-A

Ranolazine (Ranexa) prior authorization for chronic angina

Prior authorization criteria for ranolazine (Ranexa) for treatment of chronic angina, including initial and continuation duration of approval and clinical prerequisites (failed/intolerant/contraindicated to combinations of other antianginal agents or maintained clinical response). Applies to requests processed under CVS Caremark criteria for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanolazine (Ranexa) prior authorization for chronic angina

Policy CodePolicy 873-A

Change Typeclarified

Effective Date

Next Review Date

Key ActionRequests for ranolazine require prior authorization under CVS Caremark criteria and must document meeting one of the listed criteria (intolerance, contraindication, inadequate response to two agents, or maintained positive clinical response).

POLICY UPDATE CHANGES

Durations of approval specified: Initial therapy DOA 12 months; Continuation DOA 36 months.

1Indication covered (Chronic Angina)

2Required prior agents to fail/intolerant/contraindicated (count)

Coverage Summary

Ranexa (ranolazine extended-release) is FDA-approved for the treatment of chronic angina. Policy: covered_with_criteria — prior authorization criteria apply for ranolazine for chronic angina processed under CVS Caremark for Neighborhood Health Plan of Rhode Island. Authorization may be granted when the drug is prescribed for chronic angina and the patient meets one of the listed clinical criteria (see Initial Authorization and Continuation of Therapy criteria).

Provider Actions

Prior Authorization

Prior authorization required

Requests for ranolazine require prior authorization under CVS Caremark criteria and must document meeting one of the listed criteria (intolerance, contraindication, inadequate response to two agents, or maintained positive clinical response).

Documentation must show the patient meets ONE of the listed criteria: intolerance to two agents, contraindication to two agents, inadequate response to two agents, or achieved/maintained positive clinical response.

Documentation Required

Clinical documentation required

Documentation must indicate prior use and the clinical rationale relative to beta blockers, calcium channel blockers, and long-acting nitrates as applicable.

Prior use of relevant agents (beta blocker, calcium channel blocker, long-acting nitrate) as applicable
Documented intolerance to the specified agent class(es)
Documented contraindication to the specified agent class(es)
Documented clinical response (achieved or maintained) relative to baseline

Billing Rule

Duration of approval

Durations of approval specified: Initial therapy DOA 12 months; Continuation of therapy DOA 36 months.

Initial therapy DOA: 12 months
Continuation DOA: 36 months

Background

Background: Ranexa (ranolazine extended-release) is FDA-approved for chronic angina and may be used with other standard antianginal and cardiovascular therapies (for example: beta-blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE inhibitors, and ARBs). This policy cites the drug prescribing information (package inserts) and relevant clinical guidelines as evidence sources.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanolazine (Ranexa) prior authorization for chronic angina

Policy CodePolicy 873-A

Change Typeclarified

Effective Date

Next Review Date

On This Page

OpenPayer

Ranolazine (Ranexa) prior authorization for chronic angina

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Provider Actions

Applicable Codes

Clinical Evidence

Background

Revision History