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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
  • 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.
     
 
ACE Inhibitors

Tier 1

Tier 2

  • quinapril (Accupril®)
  • ramipril (Altace®)
  • captopril (Capoten®)
  • benazepril (Lotensin®)
  • trandolapril (Mavik®)
  • fosinopril (Monopril®) 
  • lisinopril (Prinivil®, Zestril®)
  • moexipril (Univasc®)
  • enalapril (Vasotec®)
  • enalaprilat (Vasotec® IV)
 
  • perindopril erbumine (Aceon®)
 
ACE/HCTZ

Tier 1

Tier 2

Tier 3

  • quinapril/HCTZ (Accuretic®)
  • captopril/HCTZ (Capozide®)
  • benazepril/HCTZ (Lotensin® HCT)
  • lisinopril/HCTZ (Prinzide®, Zestoretic®)
  • moexipril/HCTZ (Uniretic®)
  • enalapril/HCTZ (Vasoretic®)
 
  • 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 SR (Cardizem® SR)
  • diltiazem XR (Dilacor® XR)
  • felodipine (Plendil®)
  • 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)
  • amlodipine/atorvastatin (Caduet®)
  • diltiazem (Cardizem® LA)
  • diltiazem ER (Matzim® LA)
  • isradipine ( Dynacirc®)
  • nicardipine (Cardene® SR)
  • nisoldipine (Sular®)
  • verapamil (Covera® HS)
  • verapamil ER (Verelan® PM)
diltiazem CD (Cardizem® CD) 360mg 
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®)
  • enalaprilat (Vasotec® IV)
  • fosinopril (Monopril®)
  • lisinopril (Prinivil®, Zestril®)
  • losartan (Cozaar®)
  • losartan/HCTZ (Hyzaar®)
  • moexipril (Univasc®)
  • quinapril (Accupril®)
  • ramipril (Altace®)
  • trandolapril (Mavik®)
  • irbesartan (Avapro®)
  • irbesartan / HCTZ (Avalide®)
  • valsartan / HCTZ (Diovan HCT®)
 
  • 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®)
 
  • candesartan (Atacand®)
  • candesartan/HCTZ (Atacand® HCT)
  • eprosartan (Teveten®)
  • eprosartan/HCTZ (Teveten® HCT)
  • 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®)
 
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: 

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™)  

 
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.
  • Prior Authorization form
 
Antihyperlipidemics

omega-3-acid ethyl esters (Lovaza®)/omega-3-acid ethyl esters A (Omtryg™)/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 (JuxtapidTM) mipomersen (KynamroTM)

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)

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 rosuvastatin 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®)
 
* Crestor® 5mg and Crestor® 10 mg require special reason for use.
   Comparable LDL Reductions in Statins     

%LDL Reduction

Pravastatin (Pravachol®)

Simvastatin (Zocor®)

Atorvastatin (Lipitor®)

Rosuvastatin (Crestor®)

Pitavastatin (Livalo®)

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

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®)
 
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 with diagnosis of acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI).
  • 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

 
vorapaxar (Zontivity™)
  • An FDA approved diagnosis of one of the following:  history of myocardial infarction (MI) or peripheral arterial disease (PAD); AND
  • Zontivity™ must be used in combination with aspirin and/or clopidogrel (not monotherapy); AND
  • Zontivity™ will not be approved for members with the following situations: history of transient ischemic attack (TIA), stroke, or intracranial hemorrhage (ICH), or active pathological bleeding; AND
  • A quantity limit of 30 tablets per 30 days will apply.

Prior Authorization form

 
Pulmonary Arterial Hypertension

riociguat (Adempas®)

  • FDA approved diagnosis of pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension
    • Members with a diagnosis of pulmonary arterial hypertension must have previous failed trials of at least one of each of the following categories:
      • Revatio® (sildenafil) or Adcirca® (tadalafil); AND
      • Letairis® (ambrisentan) or Tracleer® (bosentan); AND
       
     
  • Members with a diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) must currently be on anticoagulation therapy; AND
  • Medical supervision by a pulmonary specialist and/or cardiologist; AND
  • Member must not be on concurrent PDE-5 inhibitor therapy; AND
  • Female members and all healthcare professionals (prescribers and dispensing pharmacies) must be enrolled in the Adempas® REMS program.
  • A quantity limit of 90 tablets per 30 days will apply.

macitentan (Opsumit®)  

  • FDA approved diagnosis of pulmonary arterial hypertension; and
  • Previous failed trials of at least one of each of the following categories:
    • Revatio® (sildenafil) or Adcirca® (tadalafil); AND
    • Letairis® (ambrisentan), or Tracleer® (bosentan); AND
     
  • Medical supervision by a pulmonary specialist and/or cardiologist; AND
  • Female members and all healthcare professionals (prescribers and dispensing pharmacies) must be enrolled in the Opsumit® REMS program.
  • A quantity limit of 30 tablets per 30 days will apply.

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®)

  • An FDA approved diagnosis of one of the following:
    • Non-valvular atrial fibrillation; OR
    • Treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) after treatment with parenteral anticoagulant for 5 to 10 days; OR
    • To reduce the risk of recurrent DVT or PE in patients who have been previously treated.
     

Prior Authorization form  

rivaroxaban (Xarelto®) / apixiban (Eliquis®)
Xarelto®
  • 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®

  • An FDA approved diagnosis of one of the following:
    • Non-valvular atrial fibrillation; OR
    • Treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) and for the reduction in the risk of recurrent DVT and PE following initial therapy; OR
    • PE or DVT prophylaxis in patients who have had hip or knee replacement surgery.
     

 Prior Authorization form

 
 Hereditary Angioedema (HAE)
icatibant (Firazyr®), ecallentide (Kalbitor®)
  • Documented diagnosis of HAE
  • Only for acute attacks of HAE

PA Forms  

C1 esterase inhibitor (Berinert®, Cinryze®)

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Dec 21, 2020
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