24:00 Cardiovascular Drugs

AMIODARONE HYDROCHLORIDE

DISOPYRAMIDE

FLECAINIDE ACETATE

MEXILETINE HYDROCHLORIDE

PROCAINAMIDE HYDROCHLORIDE

PROPAFENONE HYDROCHLORIDE

DIGOXIN

IVABRADINE (IVABRADINE HYDROCHLORIDE)

Limited use benefit (prior approval required).

For the treatment of stable chronic heart failure with New York Heart Association (NYHA) class II or III symptoms in adult patients if the following criteria are met:

• left ventricular ejection fraction ≤ 35%; and
• resting heart rate must be documented as ≥ 77 bpm on average using either an ECG on at least three separate visits or by continuous monitoring; and
• patient has had at least one hospitalization due to heart failure in the last year; and
• NYHA class II to III symptoms despite at least four weeks of treatment with an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin II receptor antagonist (ARB) in combination with a beta blocker and, if tolerated, a mineralocorticoid receptor antagonist (MRA).

CHOLESTYRAMINE RESIN

COLESEVELAM HYDROCHLORIDE

COLESTIPOL HYDROCHLORIDE

EZETIMIBE

BEZAFIBRATE

FENOFIBRATE

GEMFIBROZIL

ATORVASTATIN CALCIUM

FLUVASTATIN SODIUM

LOVASTATIN

PRAVASTATIN SODIUM

ROSUVASTATIN CALCIUM

SIMVASTATIN

ALIROCUMAB

Limited use benefit (prior approval required).

Initial Coverage (12 weeks):

• For adult patients with heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of low-density lipoprotein cholesterol (LDL-C) if the following clinical criteria are met:
• definite or probable diagnosis of HeFH using the Simon Broome or Dutch Lipid Network criteria or genetic testing;
• and

Patient is unable to reach an LDL-C target of < 2.0 mmol/L for secondary CVD prevention, or at least a 50% reduction in LDL-C from untreated baseline for primary prevention despite:

• confirmed adherence to a high-dose statin (e.g., atorvastatin 80 mg or rosuvastatin 40 mg) in combination with ezetimibe for a total of at least 3 months of continuous treatment;
• or
• patient is unable to tolerate at least two statins, with at least one statin initiated at the lowest daily starting dose; and
• for each statin (two statins in total), dose reduction was attempted to resolve intolerable myopathy or creatine kinase > 5 times the upper limit of normal rather than statin discontinuation; and
• for each statin (two statins in total), intolerable myopathy or creatine kinase > 5 times the upper limit of normal was reversed upon statin discontinuation, but reoccurred with statin rechallenge where clinically appropriate; and
• confirmed adherence to ezetimibe for a total of at least 3 months continuous treatment; and
• other known determinants of intolerable symptoms or abnormal biomarkers have been ruled out;
• or
• patient developed confirmed and documented rhabdomyolysis;
• or
• patient has a contraindication to statins; and
• confirmed adherence to ezetimibe for a total of at least 3 months continuous treatment.

Continued coverage (6 months):

• patient is adherent to therapy; and
• patient has achieved a reduction in LDL-C of at least 40% from baseline.
• Note: Annual coverage is limited to 26 prefilled syringes or prefilled pens per year.

EVOLOCUMAB

Limited use benefit (prior approval required).

Initial coverage criteria (Initial approval for 12 weeks):

For adult patients with heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of low-density lipoprotein cholesterol (LDL-C) if the following clinical criteria are met:

• definite or probable diagnosis of HeFH using the Simon Broome or Dutch Lipid Network criteria or genetic testing; and
• patient is unable to reach an LDL-C target of < 2.0 mmol/L for secondary CVD prevention, or at least a 50% reduction in LDL-C from untreated baseline for primary prevention despite:
• confirmed adherence to a high-dose statin (e.g., atorvastatin 80 mg or rosuvastatin 40 mg) in combination with ezetimibe for a total of at least 3 months of continuous treatment;
• or
• patient is unable to tolerate at least two statins, with at least one statin initiated at the lowest daily starting dose; and
• for each statin (two statins in total), dose reduction was attempted to resolve intolerable myopathy or creatine kinase > 5 times the upper limit of normal rather than statin discontinuation; and
• for each statin (two statins in total), intolerable myopathy or creatine kinase > 5 times the upper limit of normal was reversed upon statin discontinuation, but reoccurred with statin rechallenge where clinically appropriate; and
• confirmed adherence to ezetimibe for a total of at least 3 months continuous treatment; and
• other known determinants of intolerable symptoms or abnormal biomarkers have been ruled out;
• or
• patient developed confirmed and documented rhabdomyolysis;
• or
• patient has a contraindication to statins; and
• confirmed adherence to ezetimibe for a total of at least 3 months continuous treatment.

Note: Annual coverage is limited to 26 prefilled autoinjectors (140 mg every 2 weeks) or 12 automated Mini-Dosers with prefilled cartridges (420 mg once a month).

Renewal coverage criteria (Renewal for 6 months):

• patient is adherent to therapy; and
• patient has achieved a reduction in LDL-C of at least 40% from baseline.

Note: Annual coverage is limited to 26 prefilled Autoinjectors (140 mg every 2 weeks) or 12 automated Mini-Dosers with prefilled cartridges (420 mg once a month).

CLONIDINE HYDROCHLORIDE

METHYLDOPA

DIAZOXIDE

HYDRALAZINE HYDROCHLORIDE

MINOXIDIL

ISOSORBIDE DINITRATE

ISOSORBIDE-5-MONONITRATE

NITROGLYCERIN

SILDENAFIL CITRATE

Limited use benefit (prior approval required).

Must be initiated by a Pulmonary Hypertension specialist

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization.

TADALAFIL

Limited use benefit (prior approval required).

Must be initiated by a Pulmonary Hypertension specialist

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization.

AMBRISENTAN

Limited use benefit (prior approval required).

Maximum dose covered is 10 mg once daily.

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; and

• who have failed to respond to sildenafil or tadalafil; or
• who have contraindications to sildenafil or tadalafil.

BOSENTAN MONOHYDRATE

Limited use benefit (prior approval required).

Maximum dose covered is 125 mg twice daily

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; and

• who have failed to respond to sildenafil or tadalafil; or
• who have contraindications to sildenafil or tadalafil.

DIPYRIDAMOLE

DIPYRIDAMOLE, ACETYLSALICYLIC ACID

DOXAZOSIN MESYLATE

PRAZOSIN HYDROCHLORIDE

TERAZOSIN HYDROCHLORIDE

ACEBUTOLOL HYDROCHLORIDE

ATENOLOL

ATENOLOL, CHLORTHALIDONE

BISOPROLOL FUMARATE

CARVEDILOL

HYDROCHLOROTHIAZIDE, PINDOLOL

LABETALOL HYDROCHLORIDE

METOPROLOL TARTRATE

NADOLOL

PINDOLOL

PROPRANOLOL (HEMANGIOL)

Limited use benefit (prior approval required).

For the treatment of proliferating infantile hemangioma requiring systemic therapy and at least one of the following:

• life or function-threatening hemangioma; or
• ulcerated hemangioma with pain and/or lack of response to simple wound care measures; or
• hemangioma with a risk of permanent scarring or disfigurement.

PROPRANOLOL HYDROCHLORIDE

SOTALOL HYDROCHLORIDE

TIMOLOL MALEATE

AMLODIPINE BESYLATE

AMLODIPINE BESYLATE, ATORVASTATIN CALCIUM

AMLODIPINE BESYLATE, TELMISARTAN

FELODIPINE

NIFEDIPINE

NIMODIPINE

DILTIAZEM HYDROCHLORIDE

VERAPAMIL HYDROCHLORIDE

BENAZEPRIL HYDROCHLORIDE

CAPTOPRIL

CILAZAPRIL

CILAZAPRIL, HYDROCHLOROTHIAZIDE

ENALAPRIL MALEATE

ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE

FOSINOPRIL SODIUM

LISINOPRIL

LISINOPRIL, HYDROCHLOROTHIAZIDE

PERINDOPRIL ERBUMINE

PERINDOPRIL ERBUMINE, INDAPAMIDE

QUINAPRIL