Subject: Vecamyl 2992-A Supplemental Specialty PA P2023
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and
compendial uses are considered a covered benefit provided that
all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
FDA-Approved Indication
Management of moderately severe to severe essential
hypertension and in uncomplicated cases of malignant
hypertension.
All other indications are considered experimental/investigational
and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
A. Moderately severe to severe essential hypertension
Authorization of 12 months may be granted for moderately
severe to severe essential hypertension when the member
has had an inadequate response to a one month trial of a
drug combination with at least 1 medication from each of the
following classes unless the member has an intolerance or
contraindication to the drug class:
1. Diuretic
2. Angiotensin-converting enzyme inhibitor or Angiotensin II
receptor antagonist
3. Calcium channel blocker
4. Mineralocorticoid receptor antagonist (e.g.,
spironolactone)
5. Beta Blocker
B. Uncomplicated malignant hypertension
Authorization of 3 months may be granted for uncomplicated
malignant hypertension when the member has had an
inadequate response to a one month trial of a drug
combination with at least 1 medication from each of the
following classes unless the member has an intolerance or
contraindication to the drug class:
1. Diuretic
2. Angiotensin-converting enzyme inhibitor or Angiotensin II
receptor antagonist
3. Calcium channel blocker
4. Mineralocorticoid receptor antagonist (e.g.,
spironolactone)
5. Beta Blocker
Place of Service:
Outpatient
The above policy is based on the following references:
- Vecamyl [prescribing information]. New York, NY: Vyera Pharmaceuticals, LLC.; July 2018.
- Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: Detection, evaluation, and management: A scientific statement from the American Heart Association. 2018;72:e53-e90.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
November 28, 2023
