CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Uloric (febuxostat) prior authorization policy

Defines prior authorization (initial and continuation) requirements for coverage of Uloric (febuxostat) for chronic management of hyperuricemia in adults with gout, including indication-specific criteria, limitations of use, and duration of approval.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUloric (febuxostat) prior authorization policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrior authorization is required for Uloric; initial requests must meet indication criteria and either allopurinol failure/intolerance/contraindication; continuation requests must document maintained or improved clinical response.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

36 monthsDuration of Approval

AdultsCovered Population

Asymptomatic hyperuricemiaNot recommended for

Coverage Summary

Coverage stance: Covered with criteria for Uloric (febuxostat) for the chronic management of hyperuricemia in adults with gout.

Scope: Defines prior authorization requirements (initial and continuation) for Uloric in adults with gout, including indication-specific criteria, limitations of use, and duration of approval.

Initial Therapy Criteria

Initial Authorization (Not continuation of therapy)

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

ALL of the following

ALL of the following
- ONE of
  - The patient has experienced an inadequate treatment response to a maximally titrated dose of allopurinol
    Failure to achieve desired clinical response despite maximal tolerated/allopurinol titration (documentation required).
  - The patient has experienced an intolerance to allopurinol
  - Treatment with allopurinol is contraindicated or inadvisable for the patient

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Definitions & Limitations of Use

Definition — Inadequate treatment response to a maximally titrated dose of allopurinol: Failure to achieve desired clinical response despite maximal tolerated/allopurinol titration (documentation required).

Limitation: Uloric is not recommended for asymptomatic hyperuricemia.

Provider Actions

Prior Authorization

Prior authorization is required

Prior authorization is required for Uloric; initial requests must meet indication criteria and either allopurinol failure, intolerance, or contraindication; continuation requests must document maintained or improved clinical response.

Documentation Required

Document inadequate response/intolerance/contraindication or clinical response

For initial authorization, document maximal titration and inadequate response to allopurinol or intolerance/contraindication; for continuation, document positive clinical response since starting Uloric.

Billing Rule

Duration of approval (DOA)

Authorization duration for Uloric is 36 months.

Clinical Evidence & References

Evidence sources:

• Uloric [package insert], Takeda Pharmaceuticals America, Inc; August 2020.

• 2020 American College of Rheumatology guideline for the management of gout.

Background

Uloric (febuxostat) is an FDA-approved xanthine oxidase inhibitor indicated for the chronic management of hyperuricemia in adult patients with gout who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable; it is not recommended for asymptomatic hyperuricemia.

Key details:

• Duration of Approval (DOA): 36 months.

• Covered population: Adults with gout.