Subject: Ranexa PA Policy 873-A 05-2021

Drug

RANEXA  (ranolazine extended-release)

Policy:

FDA-approved Indications
Ranexa is indicated for the treatment of chronic angina.

Ranexa may be used with beta-blockers, nitrates, calcium channel blockers, anti-platelet therapy, lipid-lowering therapy, ACE inhibitors, and angiotensin receptor blockers.

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 chronic angina
      AND
      •  The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to a beta blocker used in combination with either a calcium channel blocker or long-acting nitrate

 

Place of Service:

Outpatient

The above policy is based on the following references:

References
1.  Ranexa [package insert].  Foster City, CA: Gilead Sciences, Inc.; October 2019.
2.  Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021;
     Accessed March 11, 2021.
3.  Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available
     at: https://www.micromedexsolutions.com. Accessed March 11, 2021.
4.  Fihn S, Gardin J, Abrams J. et al. American College of Cardiology Foundation/American Heart
     Association Task Force.  2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis
     and Management of Patients with Stable Ischemic Heart Disease. J Am Coll Cardiol, 60: 1-121. ACC
     Vol. 60, No. 24, December 18, 2012:2564–603. 

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.

October 01, 2021