CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Uloric (febuxostat) prior authorization

This policy governs prior authorization and coverage criteria for Uloric (febuxostat) for chronic management of hyperuricemia in adult patients with gout under the payer's pharmacy benefit. It affects providers prescribing febuxostat and pharmacy/PBM adjudication processes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUloric (febuxostat) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation of inadequate response to (or intolerance/contraindication of) a maximally titrated allopurinol dose or evidence of maintained positive clinical response for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36DOA (months)

Adults with goutIndication

30/180dAllopurinol window

Coverage Criteria for Uloric (febuxostat)

Covered when ALL of the following are met

Covered with prior authorization when the following are met:

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Main cover condition: The requested drug is being prescribed for the chronic management of hyperuricemia in an adult patient with gout

Initial therapy conditions

Not continuation of therapy with inadequate response: The request is NOT for continuation of therapy AND the patient has experienced an inadequate treatment response to a maximally titrated dose of allopurinol
From chunk 8
Not continuation of therapy with intolerance: The request is NOT for continuation of therapy AND the patient has experienced an intolerance to allopurinol
From chunk 8
Not continuation of therapy with contraindication: The request is NOT for continuation of therapy AND treatment with allopurinol is contraindicated or inadvisable for the patient
From chunks 8 and 9

Continuation therapy condition: OR the request is for continuation of therapy AND the patient has achieved or maintained a positive clinical response since beginning treatment with the requested drug

From chunks 0 and 1

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for Uloric

Prior authorization is required for Uloric (febuxostat). Coverage is provided only when the drug is prescribed for the chronic management of hyperuricemia in an adult patient with gout and the coverage criteria are met; for continuation requests, the patient must have achieved or maintained a positive clinical response since beginning treatment.

Step Therapy

Allopurinol step requirement

A step requirement for allopurinol must be met: the patient must have had an inadequate response to a maximally titrated dose of allopurinol, or have intolerance to allopurinol, or allopurinol must be contraindicated or inadvisable.

Documentation Required

Required clinical documentation

Provide documentation that the requested drug is prescribed for chronic management of hyperuricemia in an adult patient with gout, and evidence supporting one of the step conditions (inadequate response to a maximally titrated dose of allopurinol; intolerance to allopurinol; or allopurinol is contraindicated/inadvisable). For continuation requests, document maintained positive clinical response since treatment initiation.

Denial Risk

Screen-out rejection if no recent allopurinol fill

If the patient has not filled at least a 30-day supply of allopurinol within the past 180 days under the CVS Caremark-administered prescription benefit, the claim will reject with a message that a prior authorization is required.

Screen-out applies to Rx and OTC products unless otherwise stated.
If the screen-out is met (≥30-day allopurinol supply in past 180 days), the requested drug will be paid under that prescription benefit rather than processed under PA.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUloric (febuxostat) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Uloric (febuxostat) prior authorization

Coverage Criteria for Uloric (febuxostat)

Relevant Coding and Fill Window

Provider Actions, Prior Authorization, and Documentation

Background

Definitions and Indication