Norliqva (amlodipine) — Highmark
Coronary artery disease
Preferred products
- generic amlodipine besylate tablets
Initial criteria
- Member meets one of the following:
- 1. Member is age ≥ 6 years AND has a diagnosis of hypertension (ICD-10: I10)
- OR
- 2. Member is age ≥ 18 years AND has a diagnosis of coronary artery disease (ICD-10: I25)
- AND Member has an inability to swallow tablets
- AND Member has experienced therapeutic failure or intolerance to plan-preferred generic amlodipine besylate tablets
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
- Prescriber attests that the member continues to have an inability to swallow tablets
Approval duration
12 months