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The Policy VaultThe Policy Vault

Tryvio — Blue Cross Blue Shield of Kansas

hypertension

Initial criteria

  • ONE of the following:
  • A. The requested agent is eligible for continuation of therapy AND ONE of the following:
  • 1. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
  • 2. The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
  • B. BOTH of the following:
  • 1. ONE of the following:
  • A. The patient has a diagnosis of hypertension AND ONE of the following:
  • 1. The patient is still not at blood pressure goal while on triple agent therapy with 3 different antihypertensive therapy classes for at least 4 weeks OR
  • 2. The patient is unable to be on triple antihypertensive therapy with 3 different antihypertensive therapy classes OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration AND
  • 2. If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication AND
  • If the patient has a diagnosis of hypertension, then the patient will continue therapy with another antihypertensive agent in combination with the requested agent AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review] AND
  • The patient has had clinical benefit with the requested agent AND
  • ONE of the following:
  • A. If the patient has a diagnosis of hypertension, then BOTH of the following:
  • 1. The patient is currently treated with another antihypertensive agent(s) AND
  • 2. The patient will continue therapy with another antihypertensive agent(s) in combination with the requested agent OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 3 months; renewal 12 months