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
Additional Information
- Consideration for approval of Monopril-HCT® (fosinopril/HCTZ) requires the following:
- A patient specific, clinically significant reason why the member cannot use the individual components.
- Consideration for approval of Cardizem® CD (diltiazem CD) 360mg capsules requires the following:
- A patient specific, clinically significant reason why the member cannot use two 180mg Cardizem CD (diltiazem CD) capsules.
- Duration and quantity limits on the use of nimodipine oral capsules and Nymalize™ (nimodipine oral solution) will apply as follows:
- A quantity limit of 252 capsules for 21 days will apply for Nimodipine oral capsules.
- A quantity limit of 2,838 mL for 21 days will apply for Nymalize™ oral solution.
- An age restriction on the use of Epaned™ (enalapril powder for oral solution) for members aged 7 years or older will apply with the following criteria:
- Consideration for approval requires a patient specific, clinically significant reason why the member cannot swallow the oral tablet formulation even when crushed.
aliskiren oral pellets (Tekturna®) Approval Criteria:
- An FDA approved indication; AND
- A recent trial, within the previous six months and at least four weeks in duration, of an angiotensin I converting enzyme inhibitor (ACEI) [or an angiotensin II receptor blocker (ARB) if previous trial of an ACEI] and a diuretic, used concomitantly at recommended doses, that did not yield adequate blood pressure control; AND
- Member must be 6 years of age or older; AND
- A patient-specific, clinically significant reason why the member cannot use Tekturna® tablets must be provided.
amlodipine oral suspension (Katerzia™) and Norliqva® (Amlodipine Oral Solution) Approval Criteria:
- An FDA approved diagnosis of 1 of the following :
- Hypertension in adults and pediatric members 6 years of age and older; OR
- Coronary artery disease; OR
- Chronic stable angina; OR
- Vasospastic angina; AND
- A patient-specific, clinically significant reason why the member cannot use amlodipine oral tablets even when crushed must be provided; AND
- A quantity limit of 300mL per 30 days will apply.
levamlodipine tablet (Conjupri®) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use amlodipine oral tablets, which are available without prior authorization, must be provided.
lisinopril oral solution (Qbrelis™) Approval Criteria:
- An age restriction of 7 years or older will apply with the following criteria:
- A patient-specific, clinically significant reason why the member cannot use lisinopril oral tablets in place of the oral solution formulation even when the tablets are crushed.
metoprolol succinate extended-release (ER) capsules (Kapspargo™ Sprinkle) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use metoprolol succinate ER tablets, which are available without prior authorization, must be provided.
nebivolol/valsartan (Byvalson™) Approval Criteria:
- A patient-specific, clinically significant reason the member cannot use the individual components, nebivolol (Bystolic®) and valsartan (Diovan®); AND
- A quantity limit of 30 tablets per 30 days will apply.
perindopril/amlodipine (Prestalia®) Approval Criteria:
- An FDA approved diagnosis; and
- Documented trials of inadequate response to two Tier-1 angiotensin converting enzyme inhibitors (ACEIs) in combination with amlodipine; and
- A patient-specific, clinically significant reason why the member cannot use the individual components separately; and
- A quantity limit of 30 tablets per 30 days will apply.
propranolol hydrochloride oral solution (Hemangeol™) Approval Criteria:
- An FDA approved diagnosis of treatment of proliferating infantile hemangioma requiring systemic therapy.
sotalol oral solution (Sotylize™) Approval Criteria:
- An FDA approved diagnosis of life-threatening ventricular arrhythmias or for the maintenance of normal sinus rhythm in patients with highly symptomatic atrial fibrillation/flutter; and
- A patient-specific, clinically significant reason why the member cannot use sotalol oral tablets in place of the oral solution formulation; and
- A quantity limit of 64mL per day or 1,920mL per 30 days will apply.
spironolactone oral suspension (CaroSpir®) Approval Criteria:
- An FDA approved indication; AND
- A patient-specific, clinically significant reason why the member cannot use spironolactone oral tablets must be provided.
valsartan oral solution (Prexxartan®) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use valsartan oral tablets in place of the oral solution formulation even when the tablets are crushed must be provided.
ACE Inhibitors |
Tier 1
|
Tier 2
|
Special PA
|
- quinapril (Accupril®)
- perindopril erbumine (Aceon®)
- ramipril (Altace®)
- benazepril (Lotensin®)
- trandolapril (Mavik®)
- fosinopril (Monopril®)
- lisinopril (Prinivil®, Zestril®)
- moexipril (Univasc®)
- enalapril (Vasotec®)
- enalaprilat (Vasotec® IV)
|
|
- enalapril powder (Epaned®)
- lisinopril oral solution (Qbrelis®)
|
ACE/HCTZ |
Tier 1
|
Tier 2
|
Tier 3
|
- quinapril/HCTZ (Accuretic®)
- benazepril/HCTZ (Lotensin® HCT)
- lisinopril/HCTZ (Prinzide®, Zestoretic®)
- moexipril/HCTZ (Uniretic®)
- enalapril/HCTZ (Vasoretic®)
|
- captopril/HCTZ (Capozide®)
|
- fosinopril/HCTZ (Monopril-HCT®)
|
CCB (CALCIUM CHANNEL BLOCKERS) |
Tier 1
|
Tier 2
|
Special PA Criteria
|
- amlodipine (Norvasc®)
- diltiazem (Cardizem®)
- diltiazem (Tiazac®, Taztia® XT)
- diltiazem CD (Cardizem® CD)
- (All strengths except 360mg)
- diltiazem ER (Cartia® XT, Diltia® XT)
- diltiazem XR (Dilacor® XR)
- felodipine (Plendil®)
- nifedipine (Adalat®, Procardia®)
- nifedipine CC (Adalat® CC)
- nifedipine ER
- nifedipine XL (Nifedical® XL, Procardia® XL)
- nimodipine (Nimotop®)
- verapamil (Calan®, Isoptin®)
- verapamil SR (Calan® SR, Isoptin® SR)
|
- amlodipine/atorvastatin (Caduet®)
- diltiazem (Cardizem® LA)
- diltiazem ER (Matzim® LA)
- diltiazem SR (Cardizem® SR)
- isradipine ( Dynacirc®)
- nicardipine (Cardene® SR)
- nicardipine (Cardene®)
- nisoldipine (Sular®)
- verapamil (Covera® HS)
- verapamil ER (Verelan®, Verelan® PM)
|
- amlodipine oral suspension (Katerzia™)
- amlodipine oral solution (Norliqva® )
- diltiazem CD (Cardizem® CD) 360mg
- levamlodipine (Conjupri®)
|
ACE/CCB |
Tier 1
|
Tier 2
|
Tier 3
|
- Tier 1 ACE + Tier 1 CCB
- benazepril/amlodipine (Lotrel®)
|
- trandolapril/verapamil (Tarka®)
|
- perindopril/amlodipine (Prestalia®)**
|
**no products available for coverage by SoonerCare currently
ARBS (ANGIOTENSIN RECEPTOR BLOCKERS) AND ARB COMBINATIONS |
TIER 1
|
TIER 2
|
TIER 3
|
- candesartan (Atacand®)*
- irbesartan (Avapro®)
- irbesartan / HCTZ (Avalide®)
- losartan (Cozaar®)
- losartan/HCTZ (Hyzaar®)
- olmesartan/amlodipine (Azor®)
- olmesartan (Benicar®)
- olmesartan/HCTZ (Benicar® HCT)
- telmisartan (Micardis®)
- valsartan (Diovan®)
- valsartan / HCTZ (Diovan HCT®)
- valsartan/amlodipine (Exforge®)
- valsartan/amlodipine/HCTZ (Exforge® HCT)
|
- candesartan 32mg (Atacand®)
- olmesarten med/amlodipine/HCTZ (Tribenzor®)
- telmisartan/HCTZ (Micardis® HCT)
|
- azilsartan/chlorthalidone (Edarbyclor®)
- azilsartan (Edarbi®)
- candesartan/HCTZ (Atacand® HCT)
- eprosartan (Teveten®)**
- eprosartan/HCTZ (Teveten® HCT)
- telmisartan/amlodipine (Twynsta®)
|
*All strengths other than 32mg.
**no products available for coverage by SoonerCare currently
HCTZ = hydrochlorothiazide
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.
Prior Authorization form
|
TIER 1 |
TIER 2 |
TIER 3 |
- Tier 1 ACE Inhibitor + Diuretic
|
|
- aliskiren/amlodipine (Tekamlo®)**
- aliskiren (Tekturna®)
- aliskiren/HCTZ (Tekturna® HCT)
|
**no products available for coverage by SoonerCare currently