Prior Auth Protocol

Prior Authorization Protocol

PRESTALIA^R (perindopril/amlodipine)

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:
- For the treatment of hypertension to lower blood pressure in patients not adequately controlled with monotherapy or as initial therapy in patients likely to need multiple drugs to achieve their blood pressure goals
Health Net Approved Indications and Usage Guidelines:
- Medical justification must be provided why individual generic components of perindopril and amlodipine cannot be used
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
perindopril (Aceon)
2 - 16 mg PO QD
16 mg/day
amlodipine (Norvasc)
2.5 - 10 mg PO QD
10 mg/day
* Requires Prior Authorization
Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
Prestalia
3.5/2.5 mg perindopril/amlodipine PO QD, adjust dose every 1 to 2 weeks according to blood pressure goals
Length of Benefit
Product Availability:

Tablet (perindopril/amlodipine): 3.5/2.5 mg, 7/5 mg, 14/10 mg
References:

1. Prestalia [Prescribing Information]. Cincinnati, OH: Symplmed; January 2015.

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
perindopril (Aceon)	2 - 16 mg PO QD	16 mg/day
amlodipine (Norvasc)	2.5 - 10 mg PO QD	10 mg/day

Drug	Dosing Regimen	Authorization Limit
Prestalia	3.5/2.5 mg perindopril/amlodipine PO QD, adjust dose every 1 to 2 weeks according to blood pressure goals	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.