Subject: Pancrelipase PA Policy 3134-A 10-2022

Drug

PANCREATIC ENZYMES

CREON  (pancrelipase)

PANCREAZE  (pancrelipase)

PERTZYE  (pancrelipase)

VIOKACE  (pancrelipase)

ZENPEP®  (pancrelipase)

Policy:

FDA-approved Indications
Creon
Creon (pancrelipase) is indicated for the treatment of exocrine pancreatic insufficiency due to cystic fibrosis, chronic pancreatitis, pancreatectomy, or other conditions.

Pancreaze, Pertzye, Zenpep
Pancreaze, Pertzye, and Zenpep (pancrelipase) are indicated for the treatment of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions.

Viokace
Viokace (pancrelipase) tablets, in combination with a proton pump inhibitor, is indicated in adults for the treatment of exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatectomy.


COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
      •    The requested drug is being prescribed for the treatment of
            exocrine pancreatic insufficiency due to cystic fibrosis, chronic
            pancreatitis, pancreatectomy, or other conditions
      AND
      •    If the request is for Viokace, the patient will take with a proton
            pump inhibitor (PPI)

Place of Service:

Outpatient

The above policy is based on the following references:

1. Creon [package insert]. North Chicago, IL: AbbVie Inc.; June 2022.
2. Pancreaze [package insert]. Campbell, CA: Vivus, Inc.; January 2022.
3. Pertzye [package insert]. Bethlehem, PA: Digestive Care, Inc.; March 2020.
4. Viokace [package insert]. Madison, NJ: Allergan USA, Inc.; March 2020.
5. Zenpep [package insert]. Madison, NJ: Allergan USA, Inc.; March 2020.
6. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed July 29, 2022.
7. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed July 29, 2022.

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 10, 2023