Standard Commercial Drug Formulary Prior Authorization Guidelines

STANDARD COMMERCIAL DRUG FORMULARY PRIOR AUTHORIZATION GUIDELINES

LEVAMLODIPINE Generic Brand HICL GCN Medi-Span Exception/Other LEVAMLODIPINE CONJUPRI 46284 GPI-10 MALEATE (3400006728)

GUIDELINES FOR USE

1. Does the patient have a diagnosis of hypertension and meet ALL of the following criteria? • The patient is 6 years of age or older • The patient had a trial and failure of or contraindication to BOTH of the following: o TWO generic dihydropyridine calcium channel blockers (e.g., amlodipine, felodipine, nicardipine, nifedipine, etc.) o TWO other antihypertensive agents from any of the following classes: . Thiazides (e.g. hydrochlorothiazide, chlorothiazide, etc.) . Angiotensin-converting enzyme inhibitors (e.g., lisinopril, enalapril, etc.) . Angiotensin II receptor blockers (e.g., losartan, irbesartan, etc.)

If yes, approve for 12 months by HICL or GPI-10 with a quantity limit of #1 per day. If no, do not approve. DENIAL TEXT: *Some terms are already pre-defined in parenthesis. Please use these definitions if the particular text you need to use does not already have definition(s) in it.

Our guideline named LEVAMLODIPINE (Conjupri) requires the following rule(s) be met for approval: A. You have hypertension (high blood pressure) B. You are 6 years of age or older C. You have tried and failed BOTH of the following unless there is a medical reason you are unable to (contraindication): 1. TWO generic dihydropyridine calcium channel blockers (such as amlodipine, felodipine, nicardipine, nifedipine) 2. TWO other antihypertensive agents from any of the following classes: a. Thiazides (such as hydrochlorothiazide, chlorothiazide) b. Angiotensin-converting enzyme inhibitors (such as lisinopril, enalapril) c. Angiotensin II receptor blockers (such as losartan, irbesartan)

Your doctor told us [INSERT PT SPECIFIC INFO PROVIDED]. We do not have information showing you [INSERT UNMET CRITERIA]. This is why your request is denied. Please work with your doctor to use a different medication or get us more information if it will allow us to approve this request.

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STANDARD COMMERCIAL DRUG FORMULARY PRIOR AUTHORIZATION GUIDELINES

LEVAMLODIPINE RATIONALE For further information, please refer to the Prescribing Information and/or Drug Monograph for Conjupri.

REFERENCES • Conjupri [Prescribing Information]. Hong Kong: CSPC Ouyi Pharmaceutical Co., Ltd.; December 2019.

Library Commercial NSA Yes Yes No

Part D Effective: N/A Created: 10/20 Commercial Effective: 01/01/21 Client Approval: 11/20 P&T Approval: 10/20

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