Diagnosis: Cardiac/Circulatory Problems
Treatment: Pharmacy/Prescription Drugs (Edarbi)
The insurer denied Edarbi.
The denial is overturned.

The patient is a female with a past medical history significant for essential hypertension, breast cancer, and deep vein thrombosis (DVT). She has experienced significant intolerances and failed treatment with multiple anti-hypertensives from the angiotensin II receptor blockers (ARB) class including Losartan, Losartan-hydrochlorothiazide (HCTZ), Olmesartan, and valsartan. The patient currently is being treated with Edarbi (azilsartan) 40 milligrams (mg) daily with adequate control of her blood pressure. The patient's treating provider is appealing the health plan's denial of prescription benefit exception for Edarbi 40 mg.

The health plan's determination is overturned.

Based on the patient's documented intolerances and treatment failures associated with four of the listed formulary ARB medications, the patient does meet the health plan's prescription criteria for coverage of the non-formulary drug, Edarbi. In this case, ongoing treatment with Edarbi is preferable, medically appropriate, and necessary to achieve adequate blood pressure control for this patient with essential hypertension which is supported by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. (1)