CurrentNeighborhood Health Plan of Rhode IslandPolicy 540-D

Uloric (febuxostat) prior authorization

Defines prior authorization and coverage criteria for Uloric (febuxostat) for chronic management of hyperuricemia in adults with gout under the payer's pharmacy benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUloric (febuxostat) prior authorization

Policy CodePolicy 540-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document inadequate response or intolerance to maximally titrated allopurinol before coverage is approved.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36 monthsDuration of approval (DOA)

Adults with goutIndicated population

Prior authCoverage mechanism

Uloric Coverage Criteria

Coverage criteria for Uloric

Covered when ALL of the following are met

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Prior allopurinol therapy criteria: Patient has experienced an inadequate treatment response to a maximally titrated dose of allopurinol OR patient has experienced an intolerance to allopurinol OR treatment with allopurinol is contraindicated or inadvisable for the patient.

Request for new therapy must meet one of these conditions (see screen-out logic for recent allopurinol fills).

Coding and Fill Lookback

Allopurinol fill lookback (screen-out logic)

Lookback window>= 180 days (check for fills within past 180 days)

Minimum fill quantityAt least a 30‑day supply of allopurinol

InclusionsIncludes both prescription and over‑the‑counter allopurinol products unless otherwise stated

Effect of meeting screen-outIf met, the requested drug will be paid under the prescription benefit administered by CVS Caremark

Effect of not meeting screen-outIf not met, the claim will reject with a message indicating prior authorization is required

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Uloric — prior authorization required; covered when prescribed for chronic management of hyperuricemia in adults with gout and patient has inadequate response to or intolerance/contraindication to allopurinol.

Covered when prescribed for chronic management of hyperuricemia in an adult patient with gout
Requires prior authorization

Step Therapy

Allopurinol Trial Requirement

Coverage requires prior trial of maximally titrated allopurinol unless the patient is intolerant or allopurinol is contraindicated or otherwise inadvisable.

Patient must have experienced an inadequate treatment response to a maximally titrated dose of allopurinol
Or patient has experienced an intolerance to allopurinol
Or treatment with allopurinol is contraindicated or inadvisable

Documentation Required

Clinical response / Allopurinol history

Clinical response / allopurinol history — Documentation must show the patient has achieved or maintained a positive clinical response if the request is for continuation of therapy; for new requests, document inadequate response, intolerance, or contraindication to allopurinol as applicable.

For continuation requests: documentation of achieved or maintained positive clinical response since starting the requested drug
For new requests: evidence of inadequate response to maximally titrated allopurinol, intolerance to allopurinol, or contraindication/inadvisability

Denial Risk

Screen-out Rejection

Screen-out rejection — If the patient does not meet the initial screen-out logic (a recent 30-day allopurinol fill within 180 days under the CVS Caremark-administered prescription benefit), the claim will reject and a prior authorization will be required for evaluation.

Include Rx and OTC products unless otherwise stated
If patient has filled ≥30 day supply of allopurinol within past 180 days under CVS Caremark, the drug will be paid under that prescription benefit
If not, claim rejects with message indicating PA is required and PA criteria will be applied

Drug Definition

Uloric (febuxostat) — definition and labeled use

Drug class and indicationXanthine oxidase inhibitor indicated for chronic management of hyperuricemia in adult patients with gout

Use after allopurinolFor patients with inadequate response to a maximally titrated dose of allopurinol, intolerance to allopurinol, or when allopurinol is not advisable

Limitations of useNot recommended for treatment of asymptomatic hyperuricemia

Safety noteSee allopurinol prescribing information for safe and effective use of allopurinol

Background

Uloric (febuxostat) is a xanthine oxidase inhibitor indicated for the chronic management of hyperuricemia in adult patients with gout who have an inadequate response to, are intolerant of, or for whom allopurinol is not advisable. The drug is intended for ongoing management of symptomatic hyperuricemia associated with gout and, per FDA labeling, is not recommended for asymptomatic hyperuricemia. Clinical use should align with these indications when considering prior authorization and coverage.

The policy requires prior authorization for Uloric and specifies that coverage is for adult patients with gout meeting the stated criteria (inadequate response or intolerance to allopurinol, or contraindication to allopurinol). Requests should document the clinical rationale for febuxostat use and relevant prior allopurinol treatment history when applicable.