Medical Policy

Effective Date:08/01/2017 Title:Angiotensin Receptor Blockers (ARBs)
Revision Date:04/01/2018 Document:BI543:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Certain angiotensin receptor blockers (ARBs) are subject to step therapy.

2)    Target ARBs include Edarbi, and Edarbyclor.

3)    Pre-requisite ARBs include candesartan, irbesartan, losartan, olmesartan, valsartan, telmisartan, and all combination products containing these ARBs.

Medical Statement

1)    Edarbi and Edarbyclor are target drugs subject to step therapy.

2)    Members are only approved for a target ARB if they have tried and failed at least two (2) generic ARBs or ARB combo products (e.g. candesartan, irbesartan, losartan, olmesartan, valsartan or telmisartan).

Limits
Intentially left empty
Reference

1)    Clinical Pharmacology. Accessed online 7/17/2017.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.