CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Journavx (suzetrigine) coverage policy

Defines medical necessity criteria, quantity limits, coverage duration, step therapy coding logic, and exclusions for Journavx (suzetrigine) for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyJournavx (suzetrigine) coverage policy

Policy CodePolicy N/A

Change TypePolicy created

Effective DateAug 1, 2025

Next Review Date

Key ActionProvide documentation of age ≥18, moderate to severe pain, trial/failure of at least one generic pain medication within 30 days or documentation alternatives are not appropriate (or history of opioid use disorder), and that the patient will not take Journavx with a strong CYP3A4 inhibitor.

SourceLink

POLICY UPDATE CHANGES

Policy created for Journavx (suzetrigine) with medical necessity criteria, quantity limit, coverage duration, and step therapy logic.

6 weeksCoverage Duration

29/14dQuantity Limit (50 mg)

>=18Minimum Age

Coverage Summary

Coverage stance: covered_with_criteria for Journavx (suzetrigine). Scope: Defines medical necessity criteria, quantity limits, coverage duration, step therapy coding logic, and exclusions for Journavx for Neighborhood Health Plan of Rhode Island. Effective date: 08/01/2025. Last review: 05/2025. Coverage is limited to 6 weeks per authorization and subject to a quantity limit of 29 tablets per 14-day supply every 6 weeks for the 50 mg strength (an additional fill may be granted only after 6 weeks have elapsed since the initial fill).

Initial Therapy / Medical Necessity Criteria

Covered when ALL of the following are met:

ALL of the following

Patient is 18 years of age or older
Patient has documentation of moderate to severe pain
ONE of the following pain medication history requirements
- Patient has had trial and failure of 1 or more generic pain medication (NSAIDs, acetaminophen, opioid) within the previous 30 days
- Documentation specifying that alternative pain medications are not appropriate
OR: Patient has a history of opioid use disorder
This OR clause is part of the third criterion grouping
Patient will not take Journavx concomitantly with a strong CYP3A4 inhibitor (e.g., clarithromycin, itraconazole, ritonavir, ketoconazole, nefazodone, voriconazole)

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Documentation Required

Clinical documentation required for approval

Provide documentation of moderate to severe pain, age 18 years or older, and either trial and failure of at least one generic pain medication (NSAIDs, acetaminophen, opioid) within the previous 30 days or documentation that alternative pain medications are not appropriate, OR documentation of a history of opioid use disorder. Also document that the patient will not take Journavx concomitantly with a strong CYP3A4 inhibitor (e.g., clarithromycin, itraconazole, ritonavir, ketoconazole, nefazodone, voriconazole).

Step Therapy / Prior Authorization Conditions

Step Therapy / Coding Logic

Required step therapy condition for certain claims:

ALL of the following

Journavx will pay if there is at least one paid claim of a buprenorphine product for opioid dependence (examples: buprenorphine sublingual tablets, buprenorphine/naloxone sublingual tablets and films, Brixadi, or Sublocade)

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Step Therapy

Step therapy requirement for opioid dependence history

Journavx will pay only if there is at least one paid claim for a buprenorphine product for opioid dependence. Examples provided include buprenorphine sublingual tablets, buprenorphine/naloxone sublingual tablets and films, Brixadi, and Sublocade.

Examples: buprenorphine sublingual tablets
buprenorphine/naloxone sublingual tablets and films
Brixadi
Sublocade

Billing Rule

Quantity limit

Journavx 50 mg tablets: limit 29 tablets per 14-day supply every 6 weeks. An additional fill may be granted only after 6 weeks have elapsed since the initial fill.

Billing Rule

Coverage duration

Coverage duration is limited to 6 weeks per authorization.

Definitions & Drug Interaction Notes

Background: Neighborhood Health Plan of Rhode Island does not cover investigational uses. Therapies are considered investigational when used at doses or for conditions not recognized in standard compendia (AHFS-DI, DrugDex, Clinical Pharmacology, Lexi-Drugs) or not supported by peer-reviewed literature.

Definition — Strong CYP3A4 inhibitor: Examples include clarithromycin, itraconazole, ritonavir, ketoconazole, nefazodone, voriconazole.