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