Diovan HCT (valsartan/hydrochlorothiazide tablets) — Medical Mutual

Preferred products

• Candesartan and candesartan/HCTZ
• Irbesartan and irbesartan/HCTZ
• Losartan and losartan/HCTZ
• Olmesartan
• Olmesartan/HCTZ
• Olmesartan and amlodipine
• Olmesartan/amlodipine/hydrochlorothiazide tablets
• Telmisartan and telmisartan/amlodipine and telmisartan/HCTZ
• Valsartan and valsartan/amlodipine and valsartan/HCTZ and valsartan/amlodipine/hydrochlorothiazide

Initial criteria

• Coverage is provided for the non-preferred medication if the patient has had an inadequate response, experienced intolerance, OR has a contraindication to at least two preferred angiotensin receptor blockers
• Authorization may be given for Prexxartan if the patient has difficulty swallowing tablets
• Preferred Step Therapy Exception Criteria: Approve for 1 year if the patient meets ONE of the following (A, B, or C):
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR
• B. The patient has a contraindication to all preferred agents [documentation required]; OR
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• 1. The patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred agent for 90 days within a 130-day look-back period; OR
• 2. When 130 days of the patient’s prescription claims history file is unavailable, the prescriber must verify that the patient has been receiving the requested non-preferred agent for 90 days AND via paid claims (not samples or coupons); OR
• 3. There are no generic alternatives to the requested non-preferred agent

Reauthorization criteria

• Continuation of therapy may be approved for 1 year if documentation confirms ongoing use that meets initial approval conditions

Approval duration

1 year