Ranolazine extended release tablet (Ranexa®) Prior Authorization Criteria

Ranolazine extended release tablet (Ranexa®) Prior Authorization Request Form

Covered Uses

Treatment of chronic angina (ICD-9: 413)

Exclusion Criteria

• Hepatic impairment
• Treatment with potent CYP3A inhibitors, including diltiazem
• Treatment with CYP3A inducers

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

Cardiologist

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription

Other Criteria

None