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Yutrepia — Blue Cross Blue Shield of Kansas

Pulmonary arterial hypertension (PAH), WHO Group 1

Initial criteria

  • 1. ONE of the following:
  • A. BOTH of the following:
  • 1. The requested agent is eligible for continuation of therapy AND ONE of the following:
  • - The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
  • - The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
  • 2. The patient has an FDA labeled indication for the requested agent and route of administration
  • OR
  • B. The patient has a diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), WHO Group 4 and ALL of the following:
  • 1. The requested agent is Adempas AND
  • 2. The patient’s diagnosis has been confirmed by a ventilation-perfusion scan and a confirmatory selective pulmonary angiography AND
  • 3. The patient has a mean pulmonary artery pressure > 20 mmHg AND
  • 4. The patient has a pulmonary capillary wedge pressure ≤ 15 mmHg AND
  • 5. The patient has a pulmonary vascular resistance > 2 Wood units AND
  • 6. ONE of the following:
  • A. The patient is NOT a candidate for surgery OR
  • B. The patient has had a pulmonary endarterectomy AND has persistent or recurrent disease AND
  • 7. The patient will NOT be using the requested agent in combination with a PDE5 inhibitor (e.g., tadalafil [Adcirca or Cialis] or sildenafil [Revatio or Viagra])
  • OR
  • C. The patient has a diagnosis of pulmonary arterial hypertension (PAH), WHO Group 1 and ALL of the following:
  • 1. The diagnosis has been confirmed by right heart catheterization (medical records required) AND
  • 2. Mean pulmonary arterial pressure > 20 mmHg AND
  • 3. Pulmonary capillary wedge pressure ≤ 15 mmHg AND
  • 4. Pulmonary vascular resistance > 2 Wood units AND
  • 5. If the requested agent is Winrevair (sotatercept), then the patient is not pregnant or planning to become pregnant while on therapy AND
  • 6. If the requested agent is Adcirca, Adempas, Liqrev, Opsynvi, Revatio, sildenafil, Tadliq, or tadalafil, the patient will NOT be using the requested agent in combination with another PDE5 inhibitor (e.g., tadalafil [Adcirca or Cialis] or sildenafil [Revatio or Viagra]) AND
  • 7. ONE of the following:
  • A. The requested agent is not Winrevair (sotatercept) and will be utilized as monotherapy OR
  • B. The requested agent will be utilized as part of dual therapy AND ONE of the following (criteria continues beyond this excerpt)