CurrentAgency for Health Care AdministrationPolicy N/A

Arbli (losartan potassium) Prior Authorization Criteria

Customize your policy alerts

Sign up for all Agency for Health Care Administration policy alerts

Know when Agency for Health Care Administration releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs Medicaid fee-for-service prior authorization for Arbli (losartan potassium), including initial approval and continuation of therapy. It applies to providers requesting coverage for eligible patients with specified hypertension-related or diabetic nephropathy indications.

Policy Summary

PayerAgency for Health Care Administration

PolicyArbli (losartan potassium) Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

Key ActionSubmit documentation of a therapeutic trial and either insufficient efficacy, treatment-limiting adverse effects, a contraindication to preferred angiotensin II receptor blockers, or a medically justified reason preferred agents cannot be initiated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMaximum authorization length

≥ 6 yearsMinimum patient age

10 mg/mLAvailable oral suspension

Positive responseContinuation requirement

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAgency for Health Care AdministrationPolicy N/A

Arbli (losartan potassium) Prior Authorization Criteria

Customize your policy alerts

Sign up for all Agency for Health Care Administration policy alerts

Know when Agency for Health Care Administration releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAgency for Health Care Administration

PolicyArbli (losartan potassium) Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMaximum authorization length

≥ 6 yearsMinimum patient age

10 mg/mLAvailable oral suspension

Positive responseContinuation requirement

Coverage Criteria

Initial Therapy

Covered when all of the following are met, with at least one covered diagnosis pathway:

Initial therapy

Age: Patient must be at least 6 years of age.≥ 6 years
Covered indication
- Hypertension: Patient has a diagnosis of hypertension.
- Hypertension with left ventricular hypertrophy: Patient has a diagnosis of hypertension with left ventricular hypertrophy and is being treated for stroke risk reduction.
- Diabetic nephropathy: Patient has type 2 diabetes with a history of hypertension and diabetic nephropathy with an elevated serum creatinine and proteinuria.Elevated serum creatinine and proteinuria
Therapeutic trial or justification: There is evidence of a therapeutic trial and either insufficient efficacy, adverse effects limiting continued therapy, or a contraindication to preferred angiotensin II receptor blockers, including losartan; or the provider submits a medically justified explanation for why preferred agents cannot be initiated.
Documentation required.

Continuation Therapy

Continuation of therapy requires all of the following:

Continuation therapy

Initial criteria met: Patient met the initial review criteria.
Clinical response: Documentation shows a positive clinical response.Positive clinical response
Safety: Patient has not experienced any treatment-restricting adverse effects.
Appropriate dosing: Dosing is appropriate as per labeling or is supported by compendia.

Authorization and Documentation Requirements

Prior Authorization

Initial Prior Authorization Required

Prior authorization is required for initial Arbli (losartan potassium) coverage. Initial approval requires the patient to meet the clinical criteria and provide evidence supporting the request.

Patient is at least 6 years of age.
Patient has hypertension; or hypertension with left ventricular hypertrophy and is being treated for stroke-risk reduction; or type 2 diabetes with a history of hypertension and diabetic nephropathy with elevated serum creatinine and proteinuria.
A therapeutic trial of preferred angiotensin II receptor blockers, including losartan, resulted in insufficient efficacy, treatment-limiting adverse effects occurred, or a contraindication exists; a medically justified explanation is acceptable when preferred agents cannot be initiated.

Prior Authorization

Continuation Prior Authorization

Continuation authorization is required after the initial approval period. Arbli authorization is granted for 6 months when the patient met the initial review criteria and continues to demonstrate clinical benefit without treatment-restricting adverse effects.

Therapy Overview

Arbli is losartan potassium, an angiotensin II receptor blocker used for hypertension-related indications. Coverage under this policy addresses patients with hypertension; patients with hypertension and left ventricular hypertrophy receiving treatment for stroke risk reduction; and patients with type 2 diabetes, a history of hypertension, and diabetic nephropathy with elevated serum creatinine and proteinuria.

Prior authorization applies to initial and continued therapy. Initial review includes an age requirement of at least 6 years and documentation of the applicable clinical indication and preferred angiotensin II receptor blocker trial or medically justified reason preferred therapy cannot be initiated. Continued authorization requires a positive clinical response, no treatment-restricting adverse effects, and dosing appropriate under labeling or supported by compendia.

Initial Therapy Criteria

Initial therapy requires all general requirements and one covered indication pathway:

Initial therapy

Age: Patient must be at least 6 years of age.≥ 6 years
Covered indication
- Hypertension: Patient has a diagnosis of hypertension.
- Hypertension with left ventricular hypertrophy: Patient has a diagnosis of hypertension with left ventricular hypertrophy and is being treated for stroke risk reduction.

Continuation Criteria

Continuation of therapy requires all of the following:

Continuation therapy

Initial criteria met: Patient met the initial review criteria.
Clinical response: Documentation shows a positive clinical response.Positive clinical response
Safety: Patient has not experienced any treatment-restricting adverse effects.
Appropriate dosing:

Preferred Therapy Trial

Step	Requirement	Coverage
1	Document a therapeutic trial of a preferred angiotensin II receptor blocker, including losartan, with insufficient efficacy or adverse effects limiting continued therapy; alternatively, document a contraindication or medically justified explanation for why preferred agents cannot be initiated.	Covered when the requirement is met

Policy Summary

PayerAgency for Health Care Administration

PolicyArbli (losartan potassium) Prior Authorization Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

SourceLink

On This Page

Patient met the initial review criteria.
Documentation shows a positive clinical response.
Patient has not experienced treatment-restricting adverse effects.
Dosing is appropriate according to labeling or is supported by compendia.

Step Therapy

Preferred Angiotensin II Receptor Blocker Trial

Before requesting initial coverage, document a therapeutic trial of preferred angiotensin II receptor blockers, including losartan. Coverage may be considered when the trial produced insufficient efficacy, adverse effects limit continued therapy, or a contraindication exists; a medically justified explanation is required when preferred agents cannot be initiated.

Insufficient efficacy
Adverse effects limiting continued therapy
Contraindication to preferred angiotensin II receptor blockers
Medically justified explanation for why preferred agents cannot be initiated

Documentation Required

Initial Therapy Documentation

Initial review requires documentation supporting the patient's age, qualifying diagnosis, and the required preferred-agent trial or medically justified exception.

Patient age is at least 6 years.
Qualifying diagnosis: hypertension; hypertension with left ventricular hypertrophy and treatment for stroke-risk reduction; or type 2 diabetes with a history of hypertension and diabetic nephropathy with elevated serum creatinine and proteinuria.
Evidence of therapeutic trial and insufficient efficacy, treatment-limiting adverse effects, or contraindication involving preferred angiotensin II receptor blockers, including losartan; or a medically justified explanation for why preferred agents cannot be initiated.

Documentation Required

Continuation Documentation

Continuation review requires documentation that the patient qualified initially and continues to benefit from Arbli without treatment-restricting toxicity.

Initial review criteria were met.
Positive clinical response is documented.
No treatment-restricting adverse effects have occurred.
Current dosing is consistent with labeling or supported by compendia.

Denial Risk

Failure to Meet Initial Criteria

Initial Arbli coverage should be denied when the patient does not meet the initial clinical criteria or when the required supporting documentation is absent or insufficient.

Patient is younger than 6 years of age.
No qualifying diagnosis is documented.
Required evidence of a therapeutic trial, insufficient efficacy, treatment-limiting adverse effects, contraindication, or medically justified inability to initiate a preferred agent is not provided.
The request does not establish that preferred angiotensin II receptor blockers, including losartan, cannot be used.

Denial Risk

Failure to Meet Continuation Criteria

Continuation coverage should be denied when the initial criteria, ongoing clinical benefit, safety, or dosing requirements are not documented or are not met.

The patient did not meet the initial review criteria.
Positive clinical response is not documented.
Treatment-restricting adverse effects have occurred.
Dosing is not appropriate according to labeling and is not supported by compendia.

Diabetic nephropathy: Patient has type 2 diabetes with a history of hypertension and diabetic nephropathy with an elevated serum creatinine and proteinuria.Elevated serum creatinine and proteinuria

Therapeutic trial or justification: There is evidence of a therapeutic trial and either insufficient efficacy, adverse effects limiting continued therapy, or a contraindication to preferred angiotensin II receptor blockers, including losartan; or the provider submits a medically justified explanation for why preferred agents cannot be initiated.

Documentation required.

Dosing is appropriate as per labeling or is supported by compendia.