Pharmacy Prior Authorization Criteria

Angiotensin Receptor Blockers

Indications for Prior Authorization

Edarbi (azilsartan medoxomil)

For diagnosis of Hypertension
Indicated for the treatment of hypertension to lower blood pressure. Edarbi may be used alone or in combination with other antihypertensive agents.

Edarbyclor (azilsartan and chlorthalidone)

For diagnosis of Hypertension
Indicated for the treatment of hypertension, to lower blood pressure. Edarbyclor may be used in patients whose blood pressure is not adequately controlled on monotherapy. Edarbyclor may be used as initial therapy if a patient is likely to need multiple drugs to achieve blood pressure goals.

Tekturna HCT (aliskiren and hydrochlorothiazide)

For diagnosis of Hypertension
Indicated for the treatment of hypertension, to lower blood pressure. Tekturna HCT may be used in patients not adequately controlled with monotherapy. It may also be used as initial therapy in patients likely to need multiple drugs to achieve their blood pressure goals.

Exforge HCT (amlodipine, valsartan, hydrochlorothiazide)

For diagnosis of Hypertension
Indicated for the treatment of hypertension, to lower blood pressure.
Limitations of use: Exforge HCT is not indicated for the initial therapy of hypertension.

Criteria

Edarbi, Edarbyclor, Tekturna HCT

For reauthorization request, bypass criteria review and approve through 12/31/2039 For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Step Therapy

Length of Approval: When approved; no reauthorization required

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure (of a minimum 30-day supply) or intolerance to one of the following generics:

benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
benazepril-HCTZ
captopril-HCTZ
enalapril-HCTZ
fosinopril-HCTZ
lisinopril-HCTZ
quinapril-HCTZ
amlodipine-benazepril
trandolapril-verapamil
losartan
losartan-HCTZ
candesartan
candesartan-HCTZ
irbesartan
irbesartan-HCTZ
telmisartan
telmisartan-HCTZ
amlodipine-olmesartan
olmesartan
olmesartan-HCTZ
olmesartan-amlodipine-HCTZ

Exforge HCT