CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) prior authorization

Prior authorization criteria for pancreatic enzyme replacement therapies (pancrelipase products Creon, Pancreaze, Pertzye, Viokace, Zenpep) for treatment of exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions. Specifies a PPI requirement when Viokace is requested.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for pancreatic enzyme products; document that the patient has exocrine pancreatic insufficiency due to an approved etiology and, for Viokace, document co-administration with a proton pump inhibitor.

POLICY UPDATE CHANGES

No material clinical or coverage changes — policy remains current with prior authorization criteria as previously established.

5Listed Brand Products

1Products with PPI requirement

Coverage Summary

Prior authorization is required for pancreatic enzyme replacement therapies (pancrelipase products Creon, Pancreaze, Pertzye, Viokace, and Zenpep) when prescribed for the treatment of exocrine pancreatic insufficiency. Covered indications include exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions.

Initial Prior Authorization / Coverage Criteria

The requested drug will be covered with prior authorization when the following criteria are met:

ALL of the following

The requested drug is being prescribed for the treatment of exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions
Indication must be one of the listed etiologies of exocrine pancreatic insufficiency
Product-specific requirement
- Viokace PPI requirement: If the request is for Viokace, the patient will take with a proton pump inhibitor (PPI)
  Viokace tablets must be co-administered with a PPI per policy
- Other products: If the request is for Creon, Pancreaze, Pertzye, or Zenpep, no additional product-specific requirement stated
  Coverage relies on indication only for these products

ref": "b1_0

title": "Initial Prior Authorization / Coverage Criteria

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for pancreatic enzyme products (Creon, Pancreaze, Pertzye, Viokace, Zenpep); approval is granted when the drug is prescribed for exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions.

Documentation Required

Document indication

Document that the patient has exocrine pancreatic insufficiency attributable to cystic fibrosis, chronic pancreatitis, pancreatectomy, or another qualifying condition.

Documentation Required

PPI co-administration for Viokace

For Viokace requests, document that Viokace will be taken in combination with a proton pump inhibitor (PPI).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) prior authorization

Coverage Summary

Initial Prior Authorization / Coverage Criteria

Applicable Codes

Provider Actions

Clinical Evidence

Background

Revision History

Creon	pancrelipase (brand)
Pancreaze	pancrelipase (brand)
Pertzye	pancrelipase (brand)
Viokace	pancrelipase (brand) — tablets
Zenpep	pancrelipase (brand)