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Cardiovascular

Antihypertensives

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  
ACE Inhibitors

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®)  
ACE HCTZ

Tier 1

Tier 2 Tier 3
  • quinapril (Accupril®)
  • captopril (Capoten®)
  • benazepril (Lotensin®)
  • fosinopril (Monopril®)
  • lisinopril (Prinivil®, Zestril®)
  • moexipril (Univasc®)
  • enalapril (Vasotec®)    
   
CCB (Calcium Channel Blockers)

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)
ACE/CCB

Tier 1

Tier 2 Tier 3
  • Tier 1 ACE + Tier 1 CCB  
  • enalapril/felodipine (Lexxel®)
  • benazepril/amlodipine (Lotrel®)
  • trandolapril/verapamil (Tarka®)
 
ARBs (Angiotensin Receptor Blockers) and ARB combinations
*Clinical exception applies to members who have diabetes

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/KHCTZ (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®)
mecamylamine (Vecamyl™ )

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:  
    • Coronary insufficiency
    • Recent myocardial infarction
    • Rising or elevated BUN, or known renal insufficiency
    • Uremia
    • Glaucoma
    • Organic pyloric stenosis
    • Currently receiving sulfonamides or antibiotics
    • Known sensitivity to mecamylamine (Vecamyl™)   
Clonidine Products

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.
Antihyperlipidemics

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.
lomitapide (Juxtapid) mipomersen (Kynamro)

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  
HMG-CoA Reductase inhibitors (Statins)

PA Criteria: Tier 1 products available with no authorization necessary

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.
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)
 Comparable LDL Reductions in Statins

%LDL Reduction

Pravastatin (Pravachol®) Simvastatin (Zocor®) Atorvastatin (Lipitor®) Rosuvastatin (Crestor®) Pitavastatin
25-32%
31-39%
37-45%
48-52%
55-60%
60-63%
20mg
40mg
80mg
10mg
20mg
40mg
80mg
---
10mg
20mg
40mg
80mg
---
---
5mg
10mg
20mg
40mg
---
1mg
2mg
4mg
Fibric Acid Derivatives

PA Criteria:

Tier 1 products are available with no authorization necessary

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®)

Antiplatelet
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
ticagrelor (Brilinta®)

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
clopidogrel (Plavix®) 300mg
  • 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
Antiplatelet
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
ticagrelor (Brilinta®)

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
clopidogrel (Plavix®) 300mg
  • 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
Anticoagulants
dabigatran etexilate mesylate (Pradaxa®)
  • 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
rivaroxaban (Xarelto®) / apixiban (Eliquis®)
  • 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
Hereditary Angioedema (HAE)
icatibant (Firazyr®), ecallentide (Kalbitor®)
  • 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
rivaroxaban (Xarelto®) / apixiban (Eliquis®)
  • Documented diagnosis of HAE
  • Only for acute attacks of HAE

PA Forms

  • Prior Authorization form
  • Physician/Outpatient Administered
Last Modified on Jun 21, 2021
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