CurrentNeighborhood Health Plan of Rhode IslandPolicy 658-D

Ranexa (ranolazine) extended-release — Step therapy and prior authorization

Defines CVS Caremark-administered step therapy and prior authorization requirements for Ranexa (ranolazine ER) for treatment of chronic angina under the payer's prescription benefit; affects prescribers and pharmacy benefit adjudication.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanexa (ranolazine) extended-release — Step therapy and prior authorization

Policy CodePolicy 658-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the patient has not filled a 30-day supply of a beta blocker plus either a calcium channel blocker or long-acting nitrate within the past 365 days, submit prior authorization with documentation of inadequate response, intolerance, or contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12Initial DOA (months)

36Continuation DOA (months)

30 daysMinimum prior beta blocker supply

365 daysLook-back period

Coverage Criteria for Ranexa (ranolazine)

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inv-01: COVERAGE CRITERIA

Covered with prior authorization when ALL of the following are met:

Initial PA coverage

Step failure, intolerance, or contraindication to combination therapy: Patient has experienced an inadequate treatment response to a beta blocker used in combination with either a calcium channel blocker or long-acting nitrate OR patient has experienced an intolerance to a beta blocker used in combination with either a calcium channel blocker or long-acting nitrate OR patient has a contraindication to a beta blocker used in combination with either a calcium channel blocker or long-acting nitrate

Operational note: This set applies to requests that are NOT for continuation of therapy; prior authorization is required when the initial step therapy exemption has not been met.

inv-02: COVERAGE CRITERIA

Covered for continuation when ALL of the following are met:

Continuation

Clinical response: The patient has achieved or maintained a positive clinical response to treatment from baseline

Duration of approval: If approved, initial therapy DOA: 12 months; continuation of therapy DOA: 36 months

For requests that are not for continuation of therapy, the provider must document evidence of inadequate response, intolerance, or contraindication to combination therapy consisting of a beta blocker plus either a calcium channel blocker or a long-acting nitrate before ranolazine will be considered under prior authorization.

Provider Actions, Prior Authorization, and Step Therapy

Prior Authorization

Claim will reject and require prior authorization

If the patient has not met the initial step therapy requirement (see criteria below), the claim will reject with a message that a prior authorization (PA) is required. Requests submitted to the PA unit will be evaluated against the prior authorization criteria.

Affected benefit: prescription benefit administered by CVS Caremark
Operational note: Look-back period = 365 days
Affected fill: at least a 30-day supply of a beta blocker plus either a calcium channel blocker or a long-acting nitrate

Documentation Required

Required clinical justification

The provider must document that ranolazine (the requested drug) is being prescribed for the treatment of chronic angina and provide clinical justification that one of the following applies: inadequate response to, intolerance of, or contraindication to a beta blocker used in combination with either a calcium channel blocker or a long-acting nitrate. Do not submit requests for continuation of therapy under initial PA criteria.

Indication: chronic angina
Required justification: inadequate response OR intolerance OR contraindication to a beta blocker plus either a calcium channel blocker or long-acting nitrate
Operational note: Prior authorization criteria apply to requests submitted for evaluation to the PA unit

Step Therapy

Initial step therapy exemption

Prior authorization is not required if the patient has filled at least a 30-day supply of a beta blocker in combination with either a calcium channel blocker or long-acting nitrate within the past 365 days under the prescription benefit administered by CVS Caremark; in that case the requested drug will be paid under that prescription benefit.

Look-back period: 365 days
Minimum fill: ≥ 30-day supply of beta blocker + (calcium channel blocker OR long-acting nitrate)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRanexa (ranolazine) extended-release — Step therapy and prior authorization

Policy CodePolicy 658-D

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Ranexa (ranolazine) extended-release — Step therapy and prior authorization

Coverage Criteria for Ranexa (ranolazine)

Drugs and Coding References

Provider Actions, Prior Authorization, and Step Therapy

Key Definitions

Background