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Cardiovascular

apixiban (Eliquis®) Approval Criteria:

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. 

betrixaban (Bevyxxa®) Approval Criteria:

  • An FDA approved indication for the prophylaxis of venous thromboembolism (VTE) in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE; AND
  • If the member started on the medication in the hospital, number of days of treatment with betrixaban in the hospital must be provided; AND
  • Approvals will be for a maximum duration of 42 days (including use accounted for while in hospital); AND
  • A quantity limit of 43 capsules per 42 days will apply.  

dabigatran etexilate mesylate (Pradaxa®) Approval Criteria:

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.
  • Prophylaxis of DVT and PE in patients who have undergone hip replacement surgery 

edoxaban (Savaysa®) Approval Criteria:  

An FDA approved diagnosis of one of the following: 

  • To reduce the risk of stroke and systemic embolism (SE) in patients with non-valvular atrial fibrillation; OR
  • For the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) following 5 to 10 days of initial therapy with a parenteral anticoagulant; AND
  • Requests for therapy for the treatment of DVT and PE must verify that the member has undergone 5 to 10 days of initial therapy with a parenteral anticoagulant; AND
  • Members with NVAF must not have a creatinine clearance (CrCl) greater than 95mL/min because of increased risk of ischemic stroke compared to warfarin at the highest dose studied (60mg); AND
  • A quantity limit of 30 tablets per 30 days will apply.

rivaroxaban (Xarelto®) Approval Criteria:

  • An FDA approved diagnosis of one of the following:
    • Non-valvular atrial fibrillation; OR
    • Treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), to reduce the risk of recurrent DVT and PE; OR
    • Prophylaxis of DVT, which may lead to PE in patients undergoing knee or hip replacement surgery; OR
    • In combination with aspirin, to reduce the risk of major cardiovascular events [cardiovascular (CV) death, myocardial infarction (MI) and stroke] in members with chronic coronary artery disease (CAD) or peripheral artery disease (PAD); AND
    • Prophylaxis of venous thromboembolism (VTE) in acutely ill medical patients at risk for thromboembolic complications not at high risk of bleeding; AND
  • Xarelto® (rivaroxaban) 15mg and 20mg:  
    • A diagnosis of non-valvular atrial fibrillation, DVT, PE, or prophylaxis of recurrent DVT or PE will be required; OR
  • Xarelto® (rivaroxaban) 10mg:
    • One prescription for up to 39 days of therapy is allowed without prior authorization every 6 months to allow for DVT prophylaxis use in patients following hip or knee replacement surgery or for prophylaxis of VTE in acutely ill medical patients at risk for thromboembolic complications not at high risk of bleeding; OR 
  • Xarelto® (rivaroxaban) 2.5mg :
    • Must be used combination with aspirin 75-100mg to reduce the risk of major CV events in members with chronic CAD or PAD. 

Prior Authorization form

omega-3-acid ethyl esters A (Omtryg™)/icosapent ethyl (Vascepa®):

  • An FDA approved indication of 1 of the following:
    • Severe hypertriglyceridemia; and
      • Laboratory documentation of severe hypertriglyceridemia (fasting triglycerides ≥500mg/dL) and controlled diabetes mellitus [fasting glucose <150mg/dL at the time of triglycerides measurement and hemoglobin A1c (HgA1c) <7.5%]; and
      • Previous failure with fibric acid medications; and
      • Use of Vascepa® or Epanova® requires a previous failure of or a patient-specific, clinically significant reason why the member cannot use omega-3-acid ethyl esters (generic Lovaza®), which is available without prior authorization; or
    • For the use of Vascepa® as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride levels; and
      • Member must be on a stable dose of maximally tolerated statin therapy for at least 4 weeks (dosing, dates, duration of treatment, and reason for discontinuation must be provided); and
      • Laboratory documentation of fasting triglycerides ≥150mg/dL; and
      • Member must have 1 of the following:
        • Established cardiovascular disease (CVD); or
        • Diabetes mellitus and ≥2 additional risk factors for CVD; and
  • Use of Vascepa® 0.5 gram requires a patient-specific, clinically significant reason why the member cannot use Vascepa® 1 gram.
Nexletol® (Bempedoic Acid) and Nexlizet™ (Bempedoic Acid/Ezetimibe) Approval Criteria:
  • An FDA approved indication as an adjunct to diet and maximally tolerated statin therapy for the treatment of 1 of the following:
    • Heterozygous familial hypercholesterolemia (HeFH); and
      • Documentation of definite HeFH using the Simon Broome Register criteria, the Dutch Lipid Network criteria, or via genetic testing; or
    • Established atherosclerotic cardiovascular disease (ASCVD); and
      • Supporting diagnoses/conditions and dates of occurrence signifying established ASCVD; and
  • Member must be 18 years of age or older; and
  • Member must be on a stable dose of maximally tolerated statin therapy for at least 4 weeks (dosing, dates, duration of treatment, and reason for discontinuation must be provided); and
    • LDL-cholesterol (LDL-C) levels should be included following at least 4 weeks of treatment with each statin medication; and
    • Member must not be taking simvastatin at doses >20mg or pravastatin at doses >40mg due to drug interactions with Nexletol® and Nexlizet™; and
    • For statin intolerance due to myalgia, creatine kinase (CK) labs verifying rhabdomyolysis must be provided; and
  • Member requires additional lowering of LDL-cholesterol (LDL-C) (baseline, current, and goal LDL-C levels must be provided); and
  • A quantity limit of 30 tablets per 30 days will apply; and
  • Initial approvals will be for the duration of 3 months, after which time compliance and recent LDL-C levels to demonstrate the effectiveness of this medication will be required for continued approval. Subsequent approvals will be for the duration of 1 year.

Prior Authorization form

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™) Approval Criteria:  

  • An FDA approved diagnosis of hypertension or coronary artery disease; 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:  

  • 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)
  • captopril (Capoten®)
  • 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™)
  • diltiazem CD (Cardizem® CD) 360mg  
  • levamlodipine (Conjupri®)

 

ACE/CCB

Tier 1

Tier 2

Tier 3

  • Tier 1 ACE + Tier 1 CCB
  • benazepril/amlodipine (Lotrel®)
     

 

         

  • perindopril/amlodipine (Prestalia®)
  • trandolapril/verapamil (Tarka®)
  •  

     

     

    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.

    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
    • ARB + Diuretic
    • aliskiren/amlodipine (Tekamlo®)
    • aliskiren (Tekturna®)
    • aliskiren/HCTZ (Tekturna® HCT) 

     




    aspirin/dipyridamole ER (Aggrenox®)

    PA Approval Criteria:

    • An FDA approved indication for the prophylaxis of recurrent thromboembolic stroke in patients who have had transient ischemia of the brain or completed ischemic stroke due to thrombosis; AND
    • Member must be 18 years of age or older; AND
    • A patient-specific, clinically significant reason why member cannot use immediate-release dipyridamole and over-the-counter (OTC) aspirin in place of Aggrenox® must be provided.
    • A quantity limit of 60 capsules for a 30 day supply will apply.

    Prior Authorization form

    PA criteria:

    Nexiclon® XR (clonidine extended release) requires 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   

    Corlanor® (Ivabradine Tablet and Oral Solution) Approval Criteria:

    • An FDA approved indication of 1 of the following:
      • To reduce the risk of hospitalization for worsening heart failure (HF) in adult patients with stable, symptomatic chronic HF with reduced left ventricular ejection fraction; OR
      • For the treatment of stable, symptomatic HF due to dilated cardiomyopathy (DCM) in patients 6 months of age and older; AND 
    • For a diagnosis of worsening HF in adults:
      • The prescriber must verify that the member has left ventricular ejection fraction ≤35%; AND  
      • The prescriber must verify that the member is in sinus rhythm with a resting heart rate ≥70 beats per minute; AND
      • The member must be on maximal/maximally tolerated doses of beta-blockers or have a contraindication to beta-blockers; AND 
    • For a diagnosis of DCM in patients 6 months of age or older:
      • The prescriber must verify that the member has left ventricular ejection fraction ≤45%; AND
      • The prescriber must verify that the member is in sinus rhythm with a resting heart rate (HR) as follows:
        • Age 6 to 12 months, HR ≥105 beats per minute (bpm); OR
        • Age 1 to 3 years, HR ≥95 bpm; OR
        • Age 3 to 5 years, HR ≥75 bpm; OR
        • Age 5 to 18 years, HR ≥70 bpm; AND 
      • The prescriber must verify that dose titration will be followed according to package labeling; AND
      • The member’s recent weight must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling; AND 
    • Authorization of Corlanor® solution for members >40kg requires a patient-specific, clinically significant reason why Corlanor® tablets cannot be used; AND
    • For Corlanor® tablets, a quantity limit of 60 tablets per 30 days will apply; AND  
    • For Corlanor® solution, a quantity limit of 56 ampules (2 boxes) per 28 days will apply.  

    Prior Authorization form

    Entresto® (Sacubitril/Valsartan) Approval Criteria:

    • An FDA approved diagnosis of chronic heart failure (NYHA Class II, III, or IV); and
    • A quantity limit of 60 tablets per 30 days will apply. 

    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 medications; OR
    • Documented Prior Stabilization on the Tier 2 medication within the last 100 days.

    Prior Authorization form  

    Tier 1

    Tier 2

    • fenofibric acid (Fibricor® Tablets) 35mg
    • micronized fenofibrates (Lofibra® Capsules) 67mg, 134mg
    • gemfibrozil (Lopid® Tablets)
    • micronized fenofibrates (Tricor® Tablets)
    • fenofibrates (Triglide® Tablets)
    • choline fenofibrate delayed-release (Trilipix® Capsules) 45mg
    • micronized fenofibrates (Antara® Capsules)
    • fenofibrate (Fenoglide® Tablets) 
    • fenofibric acid (Fibricor® Tablets) 105mg
    • micronized fenofibrates (Lipofen® Capsules)
    • micronized fenofibrates (Lofibra® Capsules) 200mg
    • choline fenofibrate delayed-release (Trilipix® Capsules) 135mg 

     

    Cinryze® (C1 Esterase Inhibitor), Haegarda® (C1 Esterase Inhibitor), Orladeyo™ (Berotralstat), and Takhzyro® (Lanadelumab-flyo) Approval Criteria:

    • An FDA approved diagnosis of hereditary angioedema (HAE); and
    • Must be used for prophylaxis of HAE; and
    • Not currently taking an angiotensin converting enzyme (ACE) inhibitor or estrogen replacement therapy; and
    • Based on HAE attack frequency, attack severity, comorbid conditions, and member’s access to emergent treatment, the prescriber has determined long-term prophylaxis is appropriate for the member; or
    • Approval consideration will be given if the member has a recent hospitalization for a severe episode of angioedema; and
    • Authorization of Cinryze® or Haegarda® will also require a patient-specific, clinically significant reason why the member cannot use Orladeyo™; and
    • Authorization of Takhzyro® (lanadelumab-flyo) will also require a patient-specific, clinically significant reason why the member cannot use Cinryze®, Haegarda®, or Orladeyo™; and
    • Cinryze® Dosing:
      • The recommended dose of Cinryze® is 1,000 units intravenously (IV) every 3 to 4 days, approximately 2 times per week, to be infused at a rate of 1mL/min; and
      • Initial doses should be administered in an outpatient setting by a health care provider; members can be taught by their health care provider to self-administer Cinryze® IV; and
      • A quantity limit of 8,000 units per month will apply (i.e., 2 treatments per week or 8 treatments per 28 days); or
    • Haegarda® Dosing:
      • The recommended dose of Haegarda® is 60 IU/kg subcutaneously (sub-Q) twice weekly; and
      • The member’s recent weight must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling; and
      • A quantity limit of 2 treatments per week or 8 treatments per 28 days will apply; or
    • Orladeyo™ Dosing:
      • The recommended dose of Orladeyo™ is 150mg by mouth once daily; and
      • A quantity limit of 28 capsules per 28 days will apply; or
    • Takhzyro® Dosing:
      • The recommended dose of Takhzyro® is 300mg sub-Q every 2 weeks (dosing every 4 weeks may be considered in some members); and
      • Prescriber must verify member or caregiver has been trained by a health care professional on proper storage and sub-Q administration of Takhzyro®; and
      • A quantity limit of (2) 300mg/2mL vials per 28 days will apply.
    Berinert® (C1 Esterase Inhibitor), Firazyr® (Icatibant), Kalbitor® (Ecallantide), and Ruconest® (C1 Esterase Inhibitor) Approval Criteria:
    • An FDA approved diagnosis of hereditary angioedema (HAE); and
    • Must be used for the treatment of acute attacks of HAE; and
    • For authorization consideration of Firazyr® (icatibant) or Kalbitor® (ecallantide), a patient-specific, clinically significant reason why the member cannot use Berinert® (C1 esterase inhibitor) must be provided; or
    • For authorization consideration of Ruconest® (C1 esterase inhibitor), a patient-specific, clinically significant reason why the member cannot use Berinert® (C1 esterase inhibitor), Firazyr® (icatibant), or Kalbitor® (ecallantide) must be provided.
     
     

    PA Forms  

     

    Tier 1 products available with no authorization necessary

    Statin Medications Tier-2 Approval Criteria:

    • Member must have documented trials with atorvastatin and rosuvastatin, consisting of at least 8 weeks of continuous therapy each, titrated to a dose of at least 40mg atorvastatin and 20 mg rosuvastatin, which did not yield adequate LDL reduction.; OR
    • A documented adverse effect or contraindication to all available lower tiered products.

    Statin Medications Special Prior Authorization (PA) Approval Criteria:

    • Use of any Special PA medication will require a patient-specific, clinically significant reason why lower tiered medications with similar or higher LDL reduction cannot be used; AND
    • Use of FloLipid® (simvastatin oral suspension) will require a patient specific, clinically significant reason why the member cannot use simvastatin oral tablets, even when the tablets are crushed. 

    Prior Authorization form

    TIER 1

    TIER 2

    • atorvastatin (Lipitor®)
    • ezetimibe (Zetia®)
    • lovastatin (Mevacor®)
    • pravastatin (Pravachol®)
    • rosuvastatin (Crestor®)
    • simvastatin (Zocor®)
    • fluvastatin (Lescol® Lescol®  XL) 
    • lovastatin (Altoprev®)
    • pitavastatin calcium (Livalo®)
    • pitavastatin magnesium (Zypitamag™)
    • pitavastatin sodium (Nikita™)
    • simvastatin suspension (FloLipid®)
    • simvastatin/ezetimibe (Vytorin®)
    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

     

    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 tiral of high dose statin therapy (LDL reduction capability equivalent to rosuvastatin 40mg or higher) or maximally tolerated statin therapy at least 12 weeks in duration; AND
    • Documented trial of Repatha® (evolocumab) at least 12 weeks in duration; AND
    • Member requires additional lowering of LDL-C (baseline, current, and goal LDL-C levels must be provided); AND
    • Prescriber must be certified with Juxtapid™ or Kynamro™ REMS program.

    Prior Authorization form

     

    Repatha® (evolocumab) and Praluent® (alirocumab) Approval Criteria:
     
    • Member must be 13 years of age or older for the diagnosis of HoFH or must be 18 years of age or older for all other FDA-approved diagnoses or indications; AND
    • Member must be on high dose statin therapy (LDL reduction capability equivalent to rosuvastatin 40mg) or on maximally tolerated statin therapy; AND
      • Statin trials must be at least 12 weeks in duration (dosing, dates, duration of treatment, and reason for discontinuation must be provided); AND
      • LDL-cholesterol (LDL-C) levels should be included following at least 12 weeks of treatment with each statin medication; AND
      • For statin intolerance due to myalgia, creatine kinase (CK) labs verifying rhabdomyolysis must be provided; AND
      • Tier structure rules still apply; AND  
    • Member requires additional lowering of LDL-C (baseline, current, and goal LDL-C levels must be provided); AND
    • Prescriber must verify that member has been counseled on appropriate use, storage of the medication, and administration technique; AND
    • A quantity limit of two syringes or pens per 28 days will apply for Praluent®.  A quantity limit of two syringes or autoinjectors per 28 days will apply for Repatha® 140mg and a quantity limit of one autoinjector per 28 days for Repatha® 420mg.  Patients requesting Repatha® 420mg strength will not be approved for multiple 140mg syringes or autoinjectors but instead should use one 420mg autoinjector.
    • Initial approvals will be for the duration of three months.  Continued authorization at that time will require the prescriber to provide recent LDL-C levels to demonstrate the effectiveness of this medication, and compliance will be checked at that time and every six months thereafter for continued approval. 

    Repatha® (evolocumab) Approval Criteria:

    • An FDA approved diagnosis of homozygous familial hypercholesterolemia (HoFH) defined by the presence of at least one of the following:
      • 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 >500mg/dL and at least one of the following:
        • Documented evidence of definite heterozygous familial hypercholesterolemia (HeFH) in both parents; OR
        • Presence of tendinous/cutaneous xanthoma prior to age 10 years; OR  
    • An FDA approved diagnosis of primary hyperlipidemia; OR
    • An FDA approved indication to reduce the risk of myocardial infarction, stroke, and coronary revascularization in adults with established cardiovascular disease (CVD); AND
      • Documentation of established CVD; AND
        • Supporting diagnoses/conditions and dates of occurrence signifying established CVD. 

    Praluent® (alirocumab) Approval Criteria:

    • An FDA approved diagnosis of primary hyperlipidemia; OR  
    • An FDA approved indication to reduce the risk of myocardial infarction, stroke, and unstable angina requiring hospitalization in adults with established CVD; and
      • Documentation of established CVD; AND
        • Supporting diagnoses/conditions and dates of occurrence signifying established CVD; OR   

    Prior Authorization Form

    Generic Ambrisentan (Letairis®) Approval Criteria:

    • A patient-specific, clinically significant reason the member cannot use the brand formulation must be provided. 

    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. 

    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
    • Member must not have a diagnosis of pulmonary hypertension associated with idiopathic interstitial pneumonias (PH-IIP); 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. 

    selexipag (Uptravi®) Tablets  

    • An FDA approved diagnosis of pulmonary arterial hypertension (PAH); AND
    • Member must be 18 years of age or older; AND
    • Previous failed trials of at least one of each of the following categories (alone or in combination):
      • Revatio® (sildenafil) Adcirca® (tadalafil) of Adempas® (riociguat); AND
      • Letairis® (ambrisentan) or Tracleer® (bosentan); AND
      • Orenitram™ (treprostinil); AND 
    • Medical supervision by a pulmonary specialist and/or cardiologist; AND
    • A quantity limit of two tablets daily will apply for all strengths with an upper dose limit of 1,600mcg twice daily.

    sildenafil (Revatio®)

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

    sildenafil Suspension (Revatio®)  

    • An FDA approved diagnosis of pulmonary arterial hypertension; AND
    • Medical supervision by a pulmonary specialist and/or cardiologist; AND
    • An age restriction will apply. The oral suspension formulation may be approvable for ages six years and younger.  Members seven years and older must have a patient-specific, clinically significant reason why the member is not able to use the oral tablet formulation.
    • A quantity limit of 224mL per 30 days (two bottles) will apply.

    tadalafil (Adcirca®)

    • An FDA approved diagnosis of pulmonary arterial hypertension; AND
    • Medical supervision by a pulmonary specialist and/or cardiologist; AND
    • A patient-specific, clinically significant reason why the member cannot use generic sildenafil oral tablets; OR
    • A clinical exception for use as initial combination therapy with Letairis® (ambrisentan); AND
    • A quantity limit of 60 tablets per 30 days will apply.

    treprostinil (Orenitram™)  

    • An 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  
    • A quantity limit of 90 tablets per 30 days will apply. 

    Prior Authorization form

    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™)  

    Verquvo™ (Vericiguat) Approval Criteria:

    • An FDA approved indication to reduce the risk of cardiovascular death and hospitalization for heart failure (HF) in adults with all of the following:
      • Chronic symptomatic HF [New York Heart Association (NYHA) Class II, III, or IV]; and
      • Reduced left ventricular ejection fraction (LVEF) <45%; and
      • Already receiving guideline-directed medical therapy for HF, as documented in member’s pharmacy claims history; and
    • Member has evidence of worsening HF (decompensation) demonstrated by at least 1 of the following:
      • Hospitalization for HF within the past 6 months; or
      • Received outpatient intravenous (IV) diuretics within the past 3 months; and
    • Member must be 18 years of age or older; and
    • Member must not be taking concomitant soluble guanylate cyclase (sGC) stimulators (e.g., riociguat); and
    • Female members of reproductive potential must not be breastfeeding, must have a negative pregnancy test prior to initiation of therapy, and must agree to use effective contraception during treatment and for 1 month after the final dose of Verquvo™; and
    • Prescriber must agree to titrate to the target maintenance dose according to package labeling, as tolerated by the member; and
    • Initial approvals will be for the duration of 6 months. Compliance will be checked for continued approval every 6 months; and
    • A quantity limit of 30 tablets per 30 days will apply.

    • 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

     
    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 Mar 25, 2022
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