Pharmacy Prior Authorization Criteria

Tryvio (aprocitentan)

Indications for Prior Authorization

Tryvio (aprocitentan)

• For diagnosis of Hypertension
  Indicated in combination with other antihypertensive drugs, for the treatment of hypertension, to lower blood pressure (BP) in adult patients who are not adequately controlled on other drugs.

Criteria

Tryvio

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of hypertension
AND
• Patient has not achieved target blood pressure (e.g., systolic blood pressure [SBP] less than 130 mmHg) after treatment with all of the following antihypertensive medications from different classes for an adequate duration (minimum 4 weeks each) at a maximally tolerated dose:
• One of the following:
• Angiotensin converting enzyme (ACE) inhibitor (e.g., captopril, enalapril)
• Angiotensin II receptor blocker (ARB) (e.g., candesartan, valsartan)
AND
• Diuretic (e.g., hydrochlorothiazide, chlorthalidone)
AND
• Calcium channel blocker (e.g., amlodipine, nifedipine)
AND
• Mineralocorticoid receptor antagonist (MRA) [e.g., eplerenone, spironolactone]
AND
• Provider attests other causes of hypertension have been excluded (e.g., secondary causes [e.g., primary hyperaldosteronism], white coat effect, medication nonadherence) [2]
AND
• Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program) [2]
AND
• Requested drug will be used in combination with at least 3 antihypertensive medications from different classes
AND
• Prescribed by or in consultation with a specialist experienced in the treatment of resistant hypertension (e.g., cardiologist, nephrologist)

Tryvio

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., systolic blood pressure [SBP] less than 130 mmHg)
AND
• Patient continues to use Tryvio in combination with at least 3 antihypertensive medications from different classes and is adherent to therapy
AND
• Requested drug will continue to be used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community based program) [2]
AND
• Patient has been previously treated with all of the following antihypertensive medications from different classes for an adequate duration (minimum 4 weeks each) at a maximally tolerated dose:
• One of the following:
• Angiotensin converting enzyme (ACE) inhibitor (e.g., captopril, enalapril)
• Angiotensin II receptor blocker (ARB) (e.g., candesartan, valsartan)
AND
• Diuretic (e.g., hydrochlorothiazide, chlorthalidone)
AND
• Calcium channel blocker (e.g., amlodipine, nifedipine)
AND
• Mineralocorticoid receptor antagonist (MRA) [e.g., eplerenone, spironolactone]

P & T Revisions

2024-09-19, 2024-09-06

References

1. Tryvio Prescribing Information. Idorsia Pharmaceuticals US Inc. Radnor, PA. April 2024.
2. Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension. 2018;72(5).

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Revision History

• 2024-09-19: Minor update
• 2024-09-06: New Program

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