Cardiovascular

PA Criteria: Tier 1 products are covered with no authorization necessary.

Tier 2 authorization requires:

• documented inadequate response to two Tier 1 medications, or
• adverse drug reaction to all the Tier 1 medications, or
• previous stabilization on the Tier 2 medication, or
• a unique indication for which the Tier 1 antihypertensives are not indicated

Tier 3 authorization requires:

• documented inadequate response to two Tier 1 medications and documented inadequate response to all available Tier 2 medications, or
• adverse drug reaction to all the Tier 1 or all Tier 2 medications, or
• previous stabilization on the Tier 3 medication, or
• a unique indication for which the lower tiered antihypertensives are not indicated
• Prior Authorization form 

Tier 1 

Tier 2 

Tier 3 

• quinapril (Accupril®)
• ramipril (Altace®)
• captopril (Capoten®)
• benazepril (Lotensin®)
• trandolapril (Mavik®)
• fosinopril (Monopril®) 
• lisinopril (Prinivil®, Zestril®)
• moexipril (Univasc®)
• enalapril (Vasotec®)

• perindopril erbumine (Aceon®)

Tier 1 

Tier 2 

Tier 3 

• quinapril/HCTZ (Accuretic®)
• captopril/HCTZ (Capozide®)
• benazepril/HCTZ (Lotensin® HCT)
• fosinopril/HCTZ (Monopril® HCT)
• lisinopril/HCTZ (Prinzide®, Zestoretic®)
• moexipril/HCTZ (Uniretic®)
• enalapril/HCTZ (Vasoretic®)

Tier 1 

Tier 2 

• amlodipine (Norvasc®)
• diltiazem (Cardizem®)
• diltiazem (Tiazac®, Taztia® XT)
• diltiazem CD (Cardizem® CD)
• diltiazem ER (Cartia® XT, Diltia® XT)
• diltiazem SR (Cardizem® SR)
• diltiazem XR (Dilacor® XR)
• felodipine (Plendil®)
• isradipine (Dynacirc®, Dynacirc® CR)
• nicardipine (Cardene®)
• nifedipine (Adalat®, Procardia®)
• nifedipine CC (Adalat® CC)
• nifedipine ER
• nifedipine XL (Nifedical® XL, Procardia® XL)
• nimodipine (Nimotop®)
• verapamil (Calan®, Isoptin®, Verelan®)
• verapamil SR (Calan® SR, Isoptin® SR, Verelan® PM)

• amlodipine/atorvastatin (Caduet®)
• diltiazem (Cardizem® LA)
• diltiazem ER (Matzim® LA)
• nicardipine (Cardene® SR)
• nisoldipine (Sular®)
• verapamil (Covera® HS)

Tier 1 

Tier 2 

Tier 3 

• Tier 1 ACE + Tier 1 CCB

• enalapril/felodipine (Lexxel®)
• benazepril/amlodipine (Lotrel®)
• trandolapril/verapamil (Tarka®)

Tier 1 

Tier 2 

Tier 3 

• benazepril (Lotensin®)
• captopril (Capoten®)
• enalapril (Vasotec®)
• fosinopril (Monopril®)
• lisinopril (Prinivil®, Zestril®)
• losartan (Cozaar®)
• losartan/HCTZ (Hyzaar®)
• moexipril (Univasc®)
• quinapril (Accupril®)
• ramipril (Altace®)
• trandolapril (Mavik®)

• amlodopine/valsartan (Exforge®)
• amlodopine/valsartan/HCTZ (Exforge® HCT)
• amlodipine/olmesartan (Azor®)
• azilsartan/chlorthalidone (Edarbyclor®)
• azilsartan (Edarbi®)
• olmesartan (Benicar®)
• olmesartan/HCTZ (Benicar® HCT)
• olmesarten med/amlodipine/HCTZ (Tribenzor®)
• valsartan (Diovan®)
• valsartan/HCTZ (Diovan® HCT)

• candesartan (Atacand®)
• candesartan/HCTZ (Atacand® HCT)
• eprosartan (Teveten®)
• eprosartan/HCTZ (Teveten® HCT)
• irbesartan (Avapro®)
• irbesartan/HCTZ (Avalide®)
• telmisartan (Micardis®)
• telmisartan/amlodipine (Twynsta®)
• telmisartan/HCTZ (Micardis® HCT)

Direct Renin Inhibitors 

Tier 3 authorization requires:

• FDA approved indication
• Recent trial, within the previous 6 months and at least 4 weeks in duration, of an ACE Inhibitor (or an ARB if previous trial of an ACEI) and a diuretic, used concomitantly at recommended doses, that did not yield adequate blood pressure control.
• Clinical exceptions will be granted for members already currently on aliskiren and valsartan at the available doses of Valturna.
• Prior Authorization form 

Tier 1 

Tier 2 

Tier 3 

• Tier 1 ACE Inhibitor + Diuretic

• ARB + Diuretic

• aliskiren/amlodipine (Tekamlo®)
• aliskiren (Tekturna®)
• aliskiren/HCTZ (Tekturna® HCT)
• aliskiren/valsartan (Valturna®)

Consideration will be based on ALL of the following criteria:

PA criteria:

• An FDA approved diagnosis of moderately severe to severe essential hypertension or uncomplicated malignant hypertension; AND
• Use of at least 6 classes of medications, in the past 12 months, that did not yield adequate blood pressure control. Treatment must have included combination therapy with a diuretic, and therapy with at least a four-drug regimen. Medications can be from, but not limited to, the following classes: ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), direct renin inhibitors (DRIs), beta blockers, alpha blockers, alpha agonists, diuretics, etc,; AND
• Prescriber must verify member does not have ANY of the following contraindications: 

a. Coronary insufficiency
b. Recent myocardial infarction
c. Rising or elevated BUN, or known renal insufficiency
d. Uremia
e. Glaucoma
f. Organic pyloric stenosis
g. Currently receiving sulfonamides or antibiotics
h. Known sensitivity to mecamylamine (Vecamyl™)  

• Prior Authorization form  

PA criteria:

Nexiclon® XR (clonidine extended release) and Catapres TTS Patch (clonidine transdermal patch) require prior authorization with the following criteria:

• FDA-approved indication of hypertension in adults.
• Must provide a clinically significant reason why the member cannot take clonidine immediate release tablets.
• Prior Authorization form 

omega-3-acid ethyl esters (Lovaza®)/icosapent ethyl (Vascepa®) 

PA criteria:

• Laboratory documentation of severe hypertriglyceridemia (fasting triglycerides _500 mg/dL), and controlled diabetes (fasting glucose <150 mg/dL at the time of triglycerides measurement and HgA1C<7.5%), and
• Previous failure with both nicotinic acid and fibric acid medications.
• Prior Authorization form 

lomitapide (Juxtapid^TM) mipomersen (Kynamro^TM) 

PA criteria:
Consideration will be based on all of the following criteria:

• An FDA approved diagnosis of homozygous familial hypercholesterolemia defined by the presence of at least one of the following criteria:
  • A documented functional mutation(s) in both LDL receptor alleles or alleles known to affect LDL receptor functionality via genetic testing; OR
  • An untreated total cholesterol >500 mg/dL and triglycerides <300 mg/dL AND at least one of the following: 
    • Documentation that both parents have untreated total cholesterol >250 mg/dL; OR
    • Presence of tendinous / cutaneous xanthoma prior to age 10 years; AND
     
   
• Documented failure of high dose statin therapy (LDL reduction capability equivalent to atorvastatin 80mg or higher); AND
• Prescriber must be certified with Juxtapid™ or Kynamro™ REMS program.
• Prior Authorization form 

Tier 1 products available with no authorization necessary

PA Criteria:

Tier 2 authorization requires:

• A trial with atorvastatin, consisting of at least 8 weeks of continuous therapy, titrated to 40mg, which did not yield adequate LDL reduction.  The minimum starting dose of the Tier 2 medication may only be at the moderate to high LDL lowering doses (20mg rosuvastatin of higher), or
• Documented adverse effect or contraindication to all available lower tiered products, or
• Clinical exception for high risk members hospitalized for recent acute myocardial infarction or acute coronary syndrome for atorvastatin 40mg.

Tier 3 authorization requires:
To qualify for a Special PA medication, there must be:

• A clinically significant reason why lower tiered medications with similar or higher LDL reduction cannot be used.
  • simvastatin/niacin (Simcor®) and lovastatin/niacin (Advicor®) will also require a clinically significant reason why the member cannot use the individual products separately.
   
• Clinical exceptions for Ezetimibe:
  • Documented active liver disease, or
  • Documented unexplained, persistent elevations of serum transaminases, or
  • Documented statin related myopathy.
   

Prior Authorization form 

Tier 1 

Tier 2 

Tier 3 

• atorvastatin (Lipitor®)
• lovastatin (Mevacor®)
• pravastatin (Pravachol®)
• simvastatin (Zocor®)

• rosuvastatin (Crestor®)

• lovastatin/niacin (Advicor®)
• lovastatin (Altoprev®)
• fluvastatin (Lescol® Lescol®  XL)
• ezetimibe/atorvastatin (Liptruzet®)
• pitavastatin (Livalo®)
• simvastatin/niacin (Simcor®)
• simvastatin/ezetimibe (Vytorin®)
• ezetimibe (Zetia®)
• ezetimibe/atorvastatin (Liptruzet)

%LDL Reduction 

Pravastatin (Pravachol®) 

Simvastatin (Zocor®) 

Atorvastatin (Lipitor®) 

Rosuvastatin (Crestor®) 

Pitavastatin (Livalo®) 

25-32%
31-39%
37-45%
48-52%
55-60%
60-63%

5mg
10mg
20mg
40mg

1mg
2mg
4mg
 

Tier 1 products are available with no authorization necessary

PA criteria:

Tier 2 authorization requires:

• Laboratory documented failure of a tier one medication after 6 months trial, or
• Documented adverse effect, drug interaction, or contraindication to tier 1 products.
• Prior Authorization form 

Tier 1 

Tier 2 

• clofibrate (Atromid® - S)
• micronized fenofibrates (Lofibra®)
• gemfibrozil (Lopid®)
• micronized fenofibrates (Tricor®)
• fenofibrates (Trilipix®)

• micronized fenofibrates (Antara®)
• fenofibrate (Fenoglide®)
• micronized fenofibrates (Lipofen®)
• fenofibrates (Triglide®)

prasugrel (Effient®) 

The first 90 days available with no authroization required for members new to therapy.

After the first 90 days, the following criteria will apply.

• Therapy will be approved for members who are diagnosted with UA/NSTEMI and STEMI patients who are to be managed with percutaneous coronary intervention (PCI), primary or delayed.
• Length of approval will be for 1 year.
• Effient® will not be approved for members with the following situation:
  • CABG surgery
  • Members with a history of TIA or stroke
   
• Members greater than 75 years of age will generally not be approved without supporting information.
• Prior Authorization form 

The first 90 days are available with no authorization necessary.

• Therapy will be approved for members are diagnostic with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PHI).
• Length of approval will be for 1 year.
• Prior Authorization form 

• Approved for diagnosis of non-ST-Segment elevated ACUTE coronary syndrome or ST-Segment elevated ACUTE myocardial infarction.
• Approval will be for only one dose of 300mg.
• Prior Authorization form 

sildenafil (Revatio®) and tadalafil (Adcirca®)

• FDA approved diagnosis of pulmonary arterial hypertension.
• Medical supervision by a pulmonary specialist and/or cardiologist.
• Quantity limits:
  • tadalafil (Adcirca®) 20mg tabs:#60 tablets per 30 days.
  • sildenafil (Revatio®) 20mg tabs:#90 tablets per 30 days.
   
• Prior Authorization form 

• Approval will be for FDA approved indication.
• Special consideration will be given for a diagnosis of DVT when warfarin is not a viable option.
• Prior Authorization form 

• Xarelto® 10mg: One prescription for up to 35 days of therapy is allowed without prior authorization every 6 months.
• Xarelto® 15mg and 20mg: diagnosis of non valvular atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), or to reduce the risk of recurrent DVT and PE will be required.
• Eliquis® diagnosis of nonvalvular atrial fibrillation will be required.
• Prior Authorization form 

• Documented diagnosis of HAE
• Only for acute attacks of HAE

PA Forms  

• Prior Authorization form 
• Physician/Outpatient Administered 

C1 esterase inhibitor (Berinert®, Cinryze®)