aprocitentan — Blue Cross Blue Shield of Montana

Initial criteria

• ALL of the following must be met:
• 1. BOTH of the following:
• A. ONE of the following:
• 1. The patient has a diagnosis of hypertension AND ONE of the following:
• A. 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
• B. The patient is unable to be on triple antihypertensive therapy with 3 different antihypertensive therapy classes OR
• 2. The patient has another FDA labeled indication for the requested agent and route of administration AND
• B. If the patient has an FDA labeled indication, then ONE of the following:
• 1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
• 2. There is support for using the requested agent for the patient’s age for the requested indication AND
• 2. 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
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• ALL of the following must be met:
• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. ONE of the following:
• A. 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
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent
• Additional alternative approvals:
• 1. For BCBS NM Fully Insured or NM HIM members if ALL are met:
• A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• B. The requested indication is a rare disease AND
• C. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication supported in compendia for the requested agent and route of administration
• 2. For Ohio Fully Insured or HIM Shop (SG) members if ALL are met:
• A. Member resides in Ohio AND
• B. Plan is Fully Insured or HIM Shop (SG) AND
• C. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• D. ONE of the following:
• 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
• 2. The patient has another indication supported in compendia for the requested agent and route of administration OR
• 3. The prescriber has submitted TWO peer-reviewed medical journal articles supporting proposed use as generally safe and effective

Approval duration

12 months