Download Beta Blockers Bystolic

PHARMACY PRE-AUTHORIZATION CRITERIA
DRUG (S)
Beta Blockers
Bystolic (nebivolol)
Byvalson (nebivolol/valsartan)
POLICY #
11105
INDICATIONS
Bystolic and Byvalson are indicated for the treatment of hypertension, to lower blood pressure;
they may be used alone or in combination with other antihypertensive agents.
CRITERIA
Bystolic is covered only if the following prior authorization criteria are met:
• Patient has clinically documented hypertension
AND
•
An intolerance to, or treatment failure of, a trial of two of the following medications
o atenolol (Tenormin)
o bisoprolol (Zebeta)
o INNOPRAN XL
o metoprolol (Lopressor)
o metoprolol succinate (Toprol XL)
o nadolol (Corgard)
o propranolol/propranolol ER (Inderal/LA)
Byvalson is covered only if the following prior authorization criteria are met:
•
AND
•
Patient has a documented intolerance to, or treatment failure of an adequate trial of
a generic ARB (angiotensin receptor blocker)
Patient has a documented intolerance to, or treatment failure of an adequate trial of
Bystolic
Please note: Bystolic also requires Prior Authorization for members who use the Freedom
Formulary
LIMITATIONS
This Document applies to Freedom Drug List Members ONLY
(Connecticut Exchange members and most ConnectiCare SOLO Plan members)
PHARMACY PRE-AUTHORIZATION CRITERIA
DRUG (S)
Beta Blockers
Bystolic (nebivolol)
Byvalson (nebivolol/valsartan)
REFERENCES
Facts & Comparisons Online
P&T REVIEW
HISTORY
2/16, 11/16, 2/17
REVISION
RECORD
11/16