CurrentCentenePolicy CP PHAR.676

Aprocitentan (Tryvio) for hypertension

Defines medical necessity criteria, prior authorization requirements, dosing limits, contraindications, and coverage duration for Tryvio (aprocitentan) to treat hypertension across Commercial, HIM, and Medicaid lines of business affiliated with Centene Corporation.

Policy Summary

PayerCentene

PolicyAprocitentan (Tryvio) for hypertension

Policy CodePolicy CP PHAR.676

Change TypeAnnual review (no significant changes)

Effective DateJun 1, 2024

Next Review Date

Key ActionProvider must submit office chart notes, lab results or other clinical information supporting diagnosis of hypertension, recent BP within 30 days demonstrating ≥140/90 mmHg, adherence for ≥4 weeks to at least three antihypertensive classes at maximally tolerated doses, and current medication regimen showing ≥3 classes; include rationale if fewer than 3 classes due to contraindication or adverse effects.

POLICY UPDATE CHANGES

2Q 2025 annual review: no significant changes; references reviewed and updated.

Policy created and P&T approved in 05.24

1Covered indication (hypertension)

12.5 mgMaximum daily dose (tablet strength)

6 monthsInitial approval duration

3+Required concomitant antihypertensive drug classes