COVERED USES:

FDA Approved Indications:

Tekturna® (aliskiren) is indicated for the treatment of hypertension. It may be used alone or in combination with other antihypertensive agents.

Tekturna® HCT (aliskiren and hydrochlorothiazide) is indicated for the treatment of hypertension.

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Aliskiren and aliskiren/hydrochlorothiazide are covered for patients with hypertension who meet the following:

• Hypertension not controlled after an adequate trial of, or member is intolerant to, any two of the following classes of anti-hypertensive agents used alone and in combination:
  • ACE inhibitors
  • Beta blockers
  • Calcium Channel blockers
  • ARBs
  • Diuretics
  • Aldosterone inhibitors
  • Central alpha-2 agonists and other centrally acting drugs
  • Direct vasodilators

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.