CurrentNeighborhood Health Plan of Rhode IslandPolicy 658-D

Ranolazine (Ranexa) for chronic angina — Coverage Criteria

Covers clinical authorization and step therapy requirements for ranolazine (Ranexa) when prescribed for chronic angina for members of Neighborhood Health Plan of Rhode Island under the referenced drug benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanolazine (Ranexa) for chronic angina — Coverage Criteria

Policy CodePolicy 658-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization if the patient has not filled at least a 30-day supply of any two of: beta blocker, calcium channel blocker, or long-acting nitrate within the past 365 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsInitial approval

36 monthsContinuation approval

2 of 3Required prior use

365 daysLookback period

Coverage Criteria for Ranolazine (Ranexa)

Authorization may be granted when the requested drug is being prescribed for the treatment of chronic angina.

ANY of the following

The patient has experienced an inadequate treatment response to a combination of TWO of the following: beta blocker, calcium channel blocker, long-acting nitrate.
Document prior therapies, doses, and duration.
The patient has experienced an intolerance to a combination of TWO of the following: beta blocker, calcium channel blocker, long-acting nitrate.
Provide documentation of adverse effects leading to discontinuation.
The patient has a contraindication to a combination of TWO of the following: beta blocker, calcium channel blocker, long-acting nitrate.
Document specific contraindications.

ALL of the following

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanolazine (Ranexa) for chronic angina — Coverage Criteria

Policy CodePolicy 658-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization if the patient has not filled at least a 30-day supply of any two of: beta blocker, calcium channel blocker, or long-acting nitrate within the past 365 days.

SourceLink

On This Page

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The patient has a diagnosis of chronic angina (FDA-approved indication).
Ranexa may be used concomitantly with beta-blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE inhibitors, or ARBs; document concurrent therapies.
The patient has achieved or maintained a positive clinical response to treatment from baseline.
For continuation or renewal requests, provide documentation of sustained benefit.

Drug Coding and Step-Therapy Fill Evidence

Covered drugNDC | mixedCovered

ranolazine

Ranexa, ranolazine extended-release (brand and generic, all dosage forms and strengths unless otherwise stated)

Step therapy fills

Required prior fillsAt least a 30-day supply of any two of: beta blocker, calcium channel blocker, or long-acting nitrate within the past 365 days

Lookback period365 days under the prescription benefit administered by CVS Caremark

Supply length per fillMinimum 30-day supply for each qualifying fill

Claim consequence if unmetClaim will reject with a message indicating a prior authorization (PA) is required

Payment rule when metIf criteria met, the requested drug will be paid under that prescription benefit

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for ranolazine (Ranexa) when the initial step therapy requirement is not met. Submit PA requests to the plan's prior authorization unit for clinical review; approvals will be based on documentation showing inadequate response, intolerance, or contraindication to required agents, or evidence of a positive clinical response if continuing therapy.

Drug: ranolazine (Ranexa)
Submit PA to: Prior Authorization unit
PA determination based on: documented inadequate response, intolerance, contraindication, or maintained clinical benefit

Step Therapy

Step Therapy Rejection Trigger

If the patient has not filled at least a 30-day supply of any two of the following medication classes within the past 365 days—beta blocker, calcium channel blocker, or long-acting nitrate—the claim will reject at point-of-sale with an indicator that a prior authorization is required. Providers should expect claim denial messaging specifying the step therapy failure and instructing submission of a PA.

Required fills: at least a 30-day supply of any two of: beta blocker; calcium channel blocker; long-acting nitrate
Lookback period: past 365 days
Claim behavior: point-of-sale rejection with PA required indicator

Documentation Required

Clinical Support for Authorization

To support authorization, provide clinical documentation demonstrating ONE of the following: inadequate treatment response, intolerance, or contraindication to a combination of two agents from the required classes, or documentation of sustained positive clinical response if requesting continuation. Include prior medication fill history (days supply and dates), clinical notes, relevant lab or diagnostic data, and rationale for why alternatives are unsuitable.

Documentation to include: prior med fill history (dates, days' supply), clinical progress notes, adverse event documentation, contraindication evidence, objective measures of clinical response

Step Therapy

Initial Step Therapy Requirement

Initial step therapy requires that the patient has filled a prescription for at least a 30-day supply of any two of the following within the past 365 days under the prescription benefit administered by CVS Caremark: beta blocker, calcium channel blocker, long-acting nitrate. If this criterion is met, the requested drug will be processed under the prescription benefit; if not, PA is required.

Medication classes: beta blocker; calcium channel blocker; long-acting nitrate
Supply requirement: ≥ 30-day supply for each of two agents
Lookback: within past 365 days
Benefit administration: prescription benefit administered by CVS Caremark

Definitions

Chronic angina — definition and prior therapy

DefinitionChronic angina: FDA‑approved indication for ranolazine; policy applies when drug is prescribed for chronic angina.

Required prior therapy for initiationAuthorization requires inadequate response, intolerance, or contraindication to a combination of TWO of: beta blocker, calcium channel blocker, long‑acting nitrate.

Concomitant useRanolazine may be used with beta‑blockers, nitrates, or calcium channel blockers per FDA labeling.

Continuation requirementFor ongoing therapy, patient must have achieved or maintained a positive clinical response from baseline to qualify for continuation authorization.

Background

Ranolazine (Ranexa) is FDA-approved for the treatment of chronic angina. It may be used concomitantly with standard cardiovascular therapies including beta-blockers, nitrates, and calcium channel blockers. The policy bases authorization on prior inadequate response, intolerance, or contraindication to standard anti-anginal classes and requires documentation of clinical benefit for continuation of therapy.