Adcirca — Blue Cross Blue Shield of Oklahoma

pulmonary arterial hypertension

Preferred products

The patient does NOT have any FDA labeled contraindications to the requested agent AND
The patient has an indication supported in two peer-reviewed journal articles as generally safe and effective OR
The request is for a BCBS NM Fully Insured or NM HIM member and ALL of the following: the indication is a rare disease AND the patient has either another FDA labeled indication or a compendia supported indication or supporting journal articles as generally safe and effective

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
The patient has had clinical benefit with the requested agent (e.g., stabilization, decreased disease progression) AND
If the requested agent is Tyvaso for pulmonary hypertension associated with interstitial lung disease, then the patient will continue standard of care therapy for ILD (e.g., Ofev) AND
If the request is for any of the listed brand agents, then ONE of the following: (A) metastatic cancer-related use with supporting literature; OR (B) patient is currently stable on the requested agent; OR (C) patient tried and had inadequate response to corresponding generic; OR (D) generic discontinued due to lack of efficacy/adverse event; OR (E) intolerance/hypersensitivity to generic; OR (F) contraindication to generic not expected with brand; OR (G) generic expected ineffective/adverse effect/comorbidity concern/adherence issue; OR (H) brand medically necessary; OR (I) failure of another drug in same class; OR (J) support for brand over generic.
The prescriber is a specialist in or consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months