US Family Health Plan Prior Authorization Request Form for Sacubitril/valsartan (Entresto)

To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD) US Family Health Plan pharmacy program. US Family Health Plan is a TRICARE contractor for DoD.

If the prescription is to be filled through the If the prescription is to be filled at a retail USFHP Mail Order Pharmacy, check here □ pharmacy, check here □ • The completed form may be faxed to • The provider may call 1-877-880-7007 1-617-562-5296 OR OR • The patient may attach the completed form to the RETAIL • The completed form may be faxed to 617-562-5296 prescription and mail it to: Attn: Pharmacy, 77

MAIL O RDER Warren St, Brighton, MA 02135

Step Please complete patient and physician information (please print): 1 Patient Name: Physician Name: Address: Address:

Sponsor ID # Phone #: Date of Birth: Secure Fax #: Step Please complete the clinical assessment: 1. Is the initial prescription written by or in consultation with  Yes  No 2 a cardiologist? Proceed to question 2 Coverage not approved

2. Is the patient greater than or equal to 18 years of age?  Yes  No Proceed to question 3 Coverage not approved

3. Does the patient have a documented diagnosis of chronic  Yes  No heart failure (New York Heart Association class II-IV) with a left ventricular ejection fraction less than or equal to 35% Proceed to question 4 Coverage not approved with continued heart failure symptoms?

4. Is the patient receiving concomitant treatment with a  Yes  No beta-blocker that has been shown to have a survival benefit in heart failure, at maximally tolerated doses? Note: Skip to question 6 Proceed to question 5 metoprolol succinate ER 200 mg QD; carvedilol 25 mg BID or 50 mg BID if greater than 85 kg; carvedilol ER 80 mg QD; bisoprolol 10 mg QD

5. Does the patient have a contraindication to a beta-blocker?  Yes  No Note: hypersensitivity, cardiogenic shock or overt cardiac failure, second or third degree heart block, asthma, COPD Proceed to question 6 Coverage not approved

6. Has the patient been stable on any ACE inhibitor or  Yes  No preferred ARB that has shown to have benefit in heart Proceed to question 7 Coverage not approved failure (such as losartan, valsartan) for at least 4 weeks at maximally tolerated doses?

7. Does the patient have a history of angioedema due to  Yes  No an ACE inhibitor or ARB? Coverage not approved Sign and date below Step I certify the above is true to the best of my knowledge. 3 Please sign and date:

Prescriber Signature Date [ 28 September 2016 ]