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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