Pharmacy Prior Authorization Criteria

Journavx (suzetrigine) - Quantity Limit Override

Indications for Prior Authorization

Journavx (suzetrigine)

• For diagnosis of Acute Pain
  Indicated for the treatment of moderate to severe acute pain in adults.

Criteria

Journavx*

*QL is hard coded for 30 tablets per 90 days. Do not approve for greater than an additional 30 tablets per 90 days. **Claims verification required. Requests for quantities greater than 60 tablets within a 90 day period will be denied and reviewed upon appeal.

Quantity Limit

Length of Approval: 14 Day(s)

• Patient is 18 years of age or older
AND
• Patient is experiencing a new episode of moderate to severe acute pain [b]
AND
• Medication will not be used for longer than 14 days for any one acute pain occurrence [c]
AND
• Dosing frequency will be limited to twice daily
AND
• Medication is not used in combination with opioid products (e.g., oxycodone, hydrocodone, codeine)
AND
• Quantity requested does not exceed 60 tablets within the past 90 days**

P & T Revisions

2025-04-28, 2025-04-28, 2025-04-25, 2025-04-09, 2025-03-21, 2025-03-10, 2025-02-21, 2025-02-10

References

1. J Jones et al. Selective Inhibition of NaV1.8 with VX-548 for Acute Pain. N Engl J Med 2023;389:393-405. DOI: 10.1056/NEJMoa2209870. August 2023
2. D Dowell et al. Prescribing Opioids for Pain — The New CDC Clinical Practice Guideline. N Engl J Med 2022;387:2011-2013. DOI: 10. 1056/NEJMp221104. Novemebr 2023
3. Journavx Prescribing Information. Vertex Pharaceuticals Inc. Bostom MA. January 2025.

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End Notes

1. The CDC defines acute pain as pain with a duration of less than 1 month. (2)
2. The Numerical Rating Scale (NPRS-11) is an 11-point scale for self-report of pain. It is the most used unidimensional pain scale. The respondent selects a whole number (integers 0 – 10) that best reflects the intensity (or other quality if requested of his/her pain. It is categorized into no pain = 0, mild pain = 1-3, moderate pain = 4-6, severe pain = 7-10. Moderate to severe pain is evidenced by a score of greater than or equal to 4 on the Numeric Pain Rating Scale (NPRS). (1)
3. Suzetrigine was studied and found to be well tolerated for up to 14 days use at one time. (1)

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Revision History

• 2025-04-28: Update effective date to 5/1. CJ 4/28/2025
• 2025-04-28: Operational update for claims verification on quantity allowances.
• 2025-04-25: Correction of verbiage for age criterion.
• 2025-04-09: Addition of age criterion: Patient is 18 years of age or older
• 2025-03-21: Added EHB formulary to Guideline.
• 2025-03-10: Addition of QL note, requested by PA Ops.
• 2025-02-21: QL override criteria approved at Nov 2024 P&T in place.
• 2025-02-10: New Program.

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