Calcium Channel Blockers — Prior Authorization Criteria
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Defines prior authorization (PA) coverage criteria for dihydropyridine and non-dihydropyridine calcium channel blocker medications for Georgia Medicaid Fee-for-Service members, including special formulations and exception processes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Calcium Channel Blockers
Isradipine
Approvals for specific agents when ALL listed conditions are met
Supports either condition as path to approval
Liquid / suspension formulations
Approvals when ALL conditions are met
Covers liquid and suspension formulations for administration needs
NML-required products
Approvals when ALL conditions are met
Approval contingent on NML letter
Approval contingent on NML letter
Nicardipine / Nisoldipine ER
Approvals when ALL conditions are met
Requires documented failure/intolerance to 2 preferred agents
Verapamil products
Approvals when ALL conditions are met
Requires failure/intolerance across drug classes within non-dihydropyridines
Exceptions to the criteria in this policy are not handled administratively; they are considered only through the prior authorization process. To request an exception, the provider must initiate a prior authorization with OptumRx by calling 1-866-525-5827.
Initial Therapy Criteria
Initial therapy for selected agents
Initial approval conditions for non-preferred or specialty products
Agent-specific logic applies
Step Therapy Requirements
| Agent / Group | Required prior trials or documentation |
|---|---|
| Isradipine (generic) | |
| - Approvable for members with severe hypertension or hypertensive urgency; OR - Approvable for members who have experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects to at least 2 preferred dihydropyridine calcium channel blockers. | |
| Nicardipine (generic) and Nisoldipine ER (generic) | |
| Documented inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to at least 2 preferred dihydropyridine calcium channel blockers. | |
| Verapamil ER (Generic Verelan PM) and Verapamil SR 360 mg (generic) | |
| Documented inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to at least 2 preferred products (specifically 1 preferred diltiazem product and 1 preferred verapamil product). |
Provider Actions and Prior Authorization
Prior authorization required; exceptions handled via PA
Prior authorization is required for calcium channel blocker exceptions and may be initiated by calling OptumRx at 1-866-525-5827. Exceptions to the conditions of coverage are considered only through the prior authorization process.
Document required step trials of preferred agents
Approval for certain non-preferred agents requires documented inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to at least 2 preferred dihydropyridine calcium channel blockers (agent-specific requirements apply).
- Isradipine: requires failure/intolerance to >=2 preferred dihydropyridines or severe hypertension/hypertensive urgency as alternate criteria.
- Nicardipine and Nisoldipine ER: require failure/intolerance to >=2 preferred dihydropyridines.
- Verapamil ER/SR 360 mg: requires failure/intolerance to 1 preferred diltiazem product and 1 preferred verapamil product (total >=2 preferred products).
Written letter of medical necessity required
Prescriber must submit a written letter of medical necessity explaining why the preferred products are not appropriate for the member when requesting levamlodipine or diltiazem ER 360 mg / Matzim LA.
- Levamlodipine: letter explaining why generic amlodipine is not appropriate.
- Diltiazem ER 360 mg / Matzim LA: letter explaining why preferred diltiazem products are not appropriate.
Insufficient trial history can lead to denial
Requests for non-preferred agents may be denied if documentation does not show the required trial history (inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects) to the specified preferred agents.
Definitions and Abbreviations
Background
Calcium channel blockers include two pharmacologic classes: dihydropyridine agents and non-dihydropyridine agents. These medications are used primarily to treat hypertension and certain cardiac conditions. Specific formulations (for example, liquid or suspension products) and particular agents may have additional coverage requirements such as documented trials of preferred products, evidence of inability to swallow solid dosage forms or feeding tube administration, or submission of a written letter of medical necessity as described in the criteria sections.
Quantity Limits
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