CurrentOklahoma Health Care AuthorityPolicy N/A

Current Prior Authorization of Plavix and Effient

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This policy governs Oklahoma Medicaid prior authorization requirements for Plavix (clopidogrel) and Effient (prasugrel), including covered cardiovascular indications, exclusions, approval durations, and continuation requirements. The first 90 days of therapy do not require prior authorization.

Policy Summary

PayerOklahoma Health Care Authority

PolicyCurrent Prior Authorization of Plavix and Effient

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionAfter the initial 90-day period, submit authorization requests using the applicable drug-specific diagnostic criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysInitial therapy without prior authorization

1 yearStandard approval length

15 monthsContinuation supporting information required after

2,623Prior authorization requests processed in FY 2011

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CurrentOklahoma Health Care AuthorityPolicy N/A

Current Prior Authorization of Plavix and Effient

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Policy Summary

PayerOklahoma Health Care Authority

PolicyCurrent Prior Authorization of Plavix and Effient

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionAfter the initial 90-day period, submit authorization requests using the applicable drug-specific diagnostic criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysInitial therapy without prior authorization

1 yearStandard approval length

15 monthsContinuation supporting information required after

2,623Prior authorization requests processed in FY 2011

Drug-Specific Coverage Criteria

Plavix covered indications

Plavix therapy will be approved when the member has at least one of the following diagnoses or clinical situations.

ONE of the following

Member has a recent stroke.
Member has a recent myocardial infarction.
Member has established peripheral artery disease.
Member has acute coronary syndrome consisting of unstable angina or non-Q-wave myocardial infarction.
Member has undergone percutaneous coronary intervention with stent placement.
Member has a transient ischemic attack, CVA, or stroke.

Effient covered indications

Effient therapy will be approved when the member meets an approved diagnostic criterion.

ONE of the following

Member has unstable angina or non-ST-segment elevated myocardial infarction and is to be managed with primary or delayed percutaneous coronary intervention (PCI).
Member has ST-segment elevated myocardial infarction and is to be managed with primary or delayed percutaneous coronary intervention (PCI).

Effient exclusion criteria

Effient is not approved when any listed exclusion applies.

ANY of the following exclusions

Member is undergoing coronary artery bypass graft surgery.
Member has a history of transient ischemic attack or stroke.

Effient age-related review

Members older than 75 years generally require supporting information for Effient approval.

All of the following

Member is older than 75 years.
Supporting information is submitted.

Plavix 300 mg criteria

Plavix 300 mg is approved only for the specified acute coronary syndrome or myocardial infarction diagnosis and limited dosing.

All of the following

Member has an FDA-approved diagnosis of non-ST-segment elevated acute coronary syndrome or ST-segment elevated acute myocardial infarction.
Use is limited to one 300 mg dose.one 300 mg dose

Effient is not approved for members undergoing coronary artery bypass graft surgery or for members with a history of transient ischemic attack or stroke.

Prior Authorization and Documentation Actions

Note

Initial 90-day exemption

The first 90 days of therapy with Plavix or Effient do not require prior authorization.

Prior Authorization

Prior authorization after 90 days

After the initial 90-day period, obtain authorization based on the applicable drug-specific diagnostic criteria. Standard approval is for 1 year.

Billing Rule

Plavix 300 mg single dose

Plavix 300 mg is approved for only one dose when used for an FDA-approved diagnosis of non-ST-segment elevated acute coronary syndrome or ST-segment elevated acute myocardial infarction.

Approval is limited to one 300 mg dose.

Documentation Required

Support continuation after 15 months

Provide supporting information for continuation of Plavix or Effient after 15 months of therapy.

Documentation Required

Document Effient use in older members

Supporting information is required for Effient approval in members older than 75 years.

Denial Risk

Effient exclusion conditions

Effient will not be approved for members undergoing coronary artery bypass graft surgery or members with a history of transient ischemic attack or stroke.

Coronary artery bypass graft surgery
History of transient ischemic attack or stroke

Denial Risk

Effient approval for members older than 75

Members older than 75 years generally will not be approved for Effient without supporting information. Submit the required supporting information with the approval request.

Initial Therapy Requirements

Plavix initial therapy

Plavix therapy is approved when at least one approved diagnosis is present.

ONE of the following

Member has a recent stroke.
Member has a recent myocardial infarction.
Member has established peripheral artery disease.
Member has acute coronary syndrome consisting of unstable angina or non-Q-wave myocardial infarction.
Member has undergone percutaneous coronary intervention with stent placement.
Member has a transient ischemic attack, CVA, or stroke.

Effient initial therapy

Effient therapy is approved when an approved PCI-managed diagnosis is present.

ONE of the following

Member has unstable angina or non-ST-segment elevated myocardial infarction managed with primary or delayed percutaneous coronary intervention (PCI).
Member has ST-segment elevated myocardial infarction managed with primary or delayed percutaneous coronary intervention (PCI).

Policy Summary

PayerOklahoma Health Care Authority

PolicyCurrent Prior Authorization of Plavix and Effient

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionAfter the initial 90-day period, submit authorization requests using the applicable drug-specific diagnostic criteria.

SourceLink

On This Page

Current Prior Authorization of Plavix and Effient

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Current Prior Authorization of Plavix and Effient

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Drug-Specific Coverage Criteria

Prior Authorization and Documentation Actions

Therapy Overview

Initial Therapy Requirements

Continuation Therapy Requirements

Dose and Quantity Limits