CurrentAvMedPolicy N/A

Pharmacy Prior Authorization / Step-Edit for ARB and ARB-Combination Drugs

Form and criteria governing prior authorization/step-edit requests for specific angiotensin receptor blocker (ARB) drugs and ARB-combination products for AvMed members; applies to prescribers requesting coverage for listed drugs.

Policy Summary

PayerAvMed

PolicyPharmacy Prior Authorization / Step-Edit for ARB and ARB-Combination Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign the prior authorization form (handwritten signature required) and provide documentation of required prior therapy trials and supporting clinical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-3required prior therapies

30 daysminimum trial duration

requiredsignature

faxsubmission

P&T datesapproval history

Coverage Criteria for ARB and ARB-Combination Drugs

Initial coverage criteria — candesartan, candesartan-HCTZ, eprosartan

Covered when ALL of the following are met for candesartan, candesartan-HCTZ & eprosartan requests

signature_and_fields: Prescriber handwritten signature and required form fields (member, prescriber, contact, drug, dosing, diagnosis) are completed

Preprinted stamps not valid

prior_therapy: Member has tried and failed 30 days of therapy with at least TWO (2) of the listed ARB or ARB-combination agents, verified by chart notes and/or pharmacy paid claims2 agents, 30 days each

Acceptable agents: amlodipine-olmesartan; losartan; telmisartan; amlodipine-valsartan; losartan-HCTZ; valsartan; irbesartan; olmesartan; valsartan-HCTZ; irbesartan-HCTZ; olmesartan-HCTZ

Initial coverage criteria — Edarbi and Edarbyclor

Covered when ALL of the following are met for Edarbi & Edarbyclor requests

Policy Summary

PayerAvMed

PolicyPharmacy Prior Authorization / Step-Edit for ARB and ARB-Combination Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign the prior authorization form (handwritten signature required) and provide documentation of required prior therapy trials and supporting clinical records.

SourceLink

On This Page

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signature_and_fields: Prescriber handwritten signature and required form fields (member, prescriber, contact, drug, dosing, diagnosis) are completed

Preprinted stamps not valid

prior_therapy: Member has tried and failed 30 days of therapy with at least THREE (3) of the listed ARB or ARB-combination agents, verified by chart notes and/or pharmacy paid claims3 agents, 30 days each

Acceptable agents: amlodipine-olmesartan; losartan; telmisartan; amlodipine-valsartan; losartan-HCTZ; valsartan; irbesartan; olmesartan; valsartan-HCTZ; irbesartan-HCTZ; olmesartan-HCTZ

Candesartan for migraine prevention

Special indication requirement

migraine_indication: If candesartan is requested for migraine prevention, provider must submit documentation confirming the migraine indication

Documentation must be provided with the request

Use of samples to initiate therapy does not meet the step‑edit or prior authorization criteria and therefore cannot be used to satisfy the required prior‑therapy trials for authorization.

Initial Therapy Requirements

Initial therapy — candesartan, candesartan-HCTZ, eprosartan

Requirements for initiating therapy

prior_trials: Trial and failure of at least TWO listed alternative ARB/ARB-combination agents for 30 days each, verified by chart notes or pharmacy paid claims2 agents, 30 days each

Acceptable alternatives listed on form (see criteria for full list)

Initial therapy — Edarbi, Edarbyclor

Requirements for initiating therapy

prior_trials: Trial and failure of at least THREE listed alternative ARB/ARB-combination agents for 30 days each, verified by chart notes or pharmacy paid claims3 agents, 30 days each

Acceptable alternatives listed on form (see criteria for full list)

Step Therapy Requirements

Requested drug	Step requirement	Required alternative agents (examples; select all that apply)	Minimum trial duration	Verification
Edarbi (azilsartan); Edarbyclor (azilsartan-chlorthalidone)
Step: Member must have tried and failed at least THREE (3) alternative ARB or ARB-combination agents before approval
amlodipine-olmesartan; losartan; telmisartan; amlodipine-valsartan; losartan-HCTZ; valsartan; irbesartan; olmesartan; valsartan-HCTZ; irbesartan-HCTZ; olmesartan-HCTZ
30 days per agent
Verified by chart notes and/or pharmacy paid claims

Diagnosis Codes and Coding Details

Diagnosis codes (form field)ICD-10

ICD Code

ICD Code, if applicable (blank on form to be filled)

Prior therapy trial duration — 30 days

Minimum trial duration30 days per prior agent

Required number of failed agents (candesartan, candesartan-HCTZ, eprosartan)At least 2 different listed ARB or ARB-combination agents

Verification methodVerified by chart notes and/or pharmacy paid claims

Acceptable alternatives listamlodipine-olmesartan; losartan; telmisartan; amlodipine-valsartan; losartan-HCTZ; valsartan; irbesartan; olmesartan; valsartan-HCTZ; irbesartan-HCTZ; olmesartan-HCTZ

Provider Actions, Submission & Documentation Requirements

Prior Authorization

Prior Authorization Form and Submission

Prior authorization is required. The prescribing physician must sign and clearly print their name on the prior authorization form (preprinted stamps not valid). All required member, prescriber and drug information must be supplied. Fax completed forms to 1-305-671-0200. Incomplete, incorrect, or illegible submissions may delay processing or result in denial/return.

Prescriber signature and printed name required (stamps not valid).
Include member identifiers, prescriber contact (phone/fax), drug name, form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight and date obtained (if applicable).
Fax submissions to 1-305-671-0200.

Step Therapy

Step Therapy Requirement

Step therapy requirements apply and must be documented. For candesartan, candesartan‑HCTZ, and eprosartan, provide documentation (chart notes and/or pharmacy paid claims) showing the member tried and failed at least TWO (2) alternative agents for ≥ 30 days each. For Edarbi and Edarbyclor, provide documentation showing the member tried and failed at least THREE (3) alternative agents for ≥ 30 days each. Use of samples to initiate therapy does not satisfy step therapy.

Candestartan / candesartan‑HCTZ / eprosartan: failure of ≥ 2 listed alternatives for ≥ 30 days each (verified by chart notes and/or pharmacy claims).
Edarbi / Edarbyclor: failure of ≥ 3 listed alternatives for ≥ 30 days each (verified by chart notes and/or pharmacy claims).
Listed alternatives include: amlodipine‑olmesartan, losartan, telmisartan, amlodipine‑valsartan, losartan‑HCTZ, valsartan, irbesartan, olmesartan, valsartan‑HCTZ, irbesartan‑HCTZ, olmesartan‑HCTZ.

Documentation Required

Required Supporting Documentation

All required supporting documentation must be submitted with the request. Authorization may be delayed or denied if documentation is missing.

Chart notes supporting treatment history and reasons for failure/intolerance of prior agents.
Pharmacy paid-claim history verifying prior therapies and durations.
Relevant labs and diagnostic reports, when applicable.
Completed drug information section: form/strength, dosing schedule, length of therapy, diagnosis, ICD code, weight and date obtained.

Denial Risk

Incomplete or Illegible Submission

Incomplete or illegible submissions may be returned or denied. Ensure all fields on the prior authorization form are complete and legible; provide contact phone and fax numbers to avoid delays.

Missing signature, missing prescriber contact info, incomplete drug or diagnosis details, or illegible entries can delay or prevent authorization.
If the requested drug is non‑formulary under the member's plan, include documentation of medical necessity.

Definitions and Special Indications

Migraine prevention — documentation required if candesartan requested for migraine prevention

Required documentation for migraine preventionProvider must submit documentation confirming the migraine indication when candesartan is requested for migraine prevention

Applicable drugcandesartan tablets only

Where to provide evidenceAttach chart notes or other clinical documentation verifying indication

Background

This form implements AvMed’s prior authorization and step‑edit requirements for selected angiotensin receptor blocker (ARB) agents and ARB‑combination products. Prior authorization is required for the listed drugs; the prescriber must complete the authorization form, provide the member, prescriber and drug information, sign the form with a handwritten signature (preprinted stamps are not valid), and supply supporting clinical documentation as requested, including chart notes or pharmacy paid claims.

Step therapy requires documented trials and failures of specified alternative ARB or ARB‑combination agents verified by chart notes and/or pharmacy paid claims. For most requested agents the policy requires trials of preferred alternatives for a minimum of 30 days each; the number of required failed agents varies by drug (for example, at least two (2) alternative agents for candesartan/candesartan‑HCTZ/eprosartan and at least three (3) for Edarbi/Edarbyclor).

Providers must submit supporting documentation to verify prior therapy trials (chart notes and/or pharmacy paid claims). Incomplete, incorrect, or illegible submissions — including missing contact information, missing required clinical documentation, or lack of a handwritten prescriber signature — may delay or result in denial of the authorization.

If candesartan is requested for migraine prevention, the provider must submit documentation confirming that indication in addition to meeting the standard prior‑therapy and form requirements.