Prior Auth Protocol

Prior Authorization Protocol

CORLANOR^R (ivabradine)

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- To reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction <35% and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.
Health Net Approved Indications and Usage Guidelines:
- Diagnosis of heart failure
AND
- On maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use
AND
- Failure or clinically significant adverse effects to two generic beta-blockers (e.g., metoprolol, bisoprolol, carvedilol, propranolol)
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:
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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
metoprolol succinate (Toprol XL)	12.5-200 mg PO QD	200 mg/day
metoprolol tartrate (Lopressor)	6.25 mg PO BID, titrate to 50 mg PO BID	100 mg/day
carvedilol (Coreg)	3.125 - 50 mg PO BID	100 mg/day
carvedilol phosphate (Coreg CR)	10 - 80 mg PO QD	80 mg/day
bisoprolol (Zebeta)	1.25-10 mg PO QD	10 mg/day
propranolol	30 mg PO TID	90 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
Corlanor
Initial starting dose 5 mg PO BID; after 2 weeks adjust dose based on heart rate; maximum dose is 7.5 mg PO BID
Length of Benefit
Product Availability:

Tablet: 5, 7.5 mg
References:

1. Corlanor [Prescribing Information]. Thousand Oaks, CA: Amgen Inc. April 2015.

Drug	Dosing Regimen	Authorization Limit
Corlanor	Initial starting dose 5 mg PO BID; after 2 weeks adjust dose based on heart rate; maximum dose is 7.5 mg PO BID	Length of Benefit

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.