CurrentNeighborhood Health Plan of Rhode IslandPolicy 2557-D

Savella

Step therapy and post-step prior authorization criteria for coverage of Savella (milnacipran) for management of fibromyalgia in adults under CVS Caremark-administered benefits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySavella

Policy CodePolicy 2557-D

Change Typeclarified

Effective Date

Next Review Date

Key ActionIf patient did not fill a ≥30-day supply of immediate-release pregabalin or duloxetine within the past 120 days under CVS Caremark, the claim will reject and a prior authorization is required; submitted requests will be evaluated against the PA criteria.

SourceLink

POLICY UPDATE CHANGES

Document indicates Initial therapy DOA: 6 months; Continuation DOA: 36 months.

1FDA-approved indication covered

18+Minimum age for coverage

120Lookback period (days)

6 / 36Initial / Continuation DOA (months)

Coverage Summary

Savella (milnacipran) is FDA-approved for the management of fibromyalgia in adults and is covered with criteria (covered_with_criteria) under CVS Caremark-administered benefits. Coverage requires step therapy: prior fill of at least a 30‑day supply of immediate‑release pregabalin or duloxetine within the past 120 days before Savella will be paid; if the step is not met the claim will reject and prior authorization is required. The policy applies to adults 18 years of age or older. Initial and continuation durations of approval are 6 months and 36 months, respectively.

Initial Step Therapy Criteria

Initial Step Therapy

If prior fill of specified comparators exists, requested drug will be paid; otherwise claim rejects and PA is required.

ALL of the following

Patient has filled a prescription for at least a 30 day supply of immediate-release pregabalin or duloxetine within the past 120 days under a prescription benefit administered by CVS Caremark>= 30 day supply, lookback 120 days
If met, requested drug will be paid; if not, claim rejects and PA is required

If the patient does not meet the initial step therapy criteria, then the claim will reject with a message indicating that a prior authorization (PA) is required.

Step Therapy

Step therapy enforced — prior comparator fill required

If the patient did not fill a ≥30-day supply of immediate‑release pregabalin or duloxetine within the past 120 days under a prescription benefit administered by CVS Caremark, the claim will reject and a prior authorization is required.

Comparator agents: immediate‑release pregabalin, duloxetine
Lookback period: ≥30-day supply within the past 120 days

Prior Authorization: Initial Coverage Criteria

Coverage Criteria for Prior Authorization

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

ALL of the following

Requested drug is being prescribed for the treatment of fibromyalgia
Patient is 18 years of age or older
One of the following for non-continuation requests
- Patient has experienced an inadequate treatment response to duloxetine
- Patient has experienced an intolerance to duloxetine
- Patient has a contraindication that would prohibit a trial of duloxetine
Request is NOT for continuation of therapy

Prior Authorization

Prior authorization required for Savella when step not satisfied

If the initial step therapy requirement is not met the claim will reject and a prior authorization is required; submitted requests will be evaluated against the PA criteria (policy 2557-D).

Submitted requests are evaluated against the PA criteria
Policy identifier: 2557-D

Documentation Required

PA documentation for initial coverage

For initial prior authorization, document the diagnosis of fibromyalgia, that the patient is ≥18 years of age, and evidence of an inadequate response, intolerance, or contraindication to duloxetine (unless this is a continuation request).

Continuation Therapy Criteria

Continuation of Therapy

Criteria for renewal of an existing Savella authorization

ALL of the following

The request is for continuation of therapy
The patient has achieved or maintained a positive clinical response to the requested drug (e.g., improvement in pain)

Documentation Required

Continuation documentation

For continuation (renewal) requests, document that the patient has achieved or maintained a positive clinical response to the requested drug (e.g., improvement in pain).

Billing Rule

Duration of Approval

Initial DOA: 6 months; Continuation DOA: 36 months.

Policy identifier: 2557-D
Initial therapy DOA = 6 months; Continuation DOA = 36 months

Provider Actions & What To Do

Prior Authorization

If patient did not fill a ≥30-day supply of immediate-release pregabalin or duloxetine within the past 120 days under CVS Caremark, the claim will reject and a prior authorization is required; submitted requests will be evaluated against the PA criteria.

Documentation Required

PA criteria for initial coverage

Document fibromyalgia diagnosis, patient age ≥18 years, and evidence of inadequate response, intolerance, or contraindication to duloxetine (unless continuation request).

Documentation Required

Continuation documentation

Document that the patient has achieved or maintained a positive clinical response for continuation requests.

Billing Rule

Duration of Approval

Initial DOA = 6 months; Continuation DOA = 36 months (policy identifier 2557-D).

Policy identifier: 2557-D

Background

Savella is indicated for the management of fibromyalgia in adults. Under CVS Caremark step therapy, a patient must have filled a prescription for at least a 30‑day supply of immediate‑release pregabalin or duloxetine within the past 120 days for the requested drug to be paid; otherwise the claim will reject and a prior authorization is required. For PA consideration, criteria include documentation of fibromyalgia diagnosis, patient age ≥ 18 years, and either an inadequate response, intolerance, or a contraindication to duloxetine (unless the request is for continuation of therapy). Continuation requests require documentation of a maintained positive clinical response to Savella.

Definitions

DOADuration of Approval

PAPrior Authorization

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySavella

Policy CodePolicy 2557-D

Change Typeclarified

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Savella

Coverage Summary

Initial Step Therapy Criteria

Prior Authorization: Initial Coverage Criteria

Continuation Therapy Criteria

Applicable Codes & Drug Identifiers

Provider Actions & What To Do

Clinical Evidence & References

Background

Revision History

Savella	Brand name for milnacipran
milnacipran	Generic name
duloxetine	Comparator agent referenced (Cymbalta)
pregabalin	Comparator agent referenced (immediate-release formulation)