Adcirca — CareFirst (Caremark)
Pulmonary arterial hypertension (PAH) (World Health Organization Group 1) to improve exercise ability
Initial criteria
- Medication must be prescribed by or in consultation with a pulmonologist or cardiologist for the diagnosis of PAH
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension
- PAH was confirmed by either of the following:
- Pretreatment right heart catheterization with all of the following results: mean pulmonary arterial pressure (mPAP) > 20 mmHg; pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg; pulmonary vascular resistance (PVR) > 2 Wood units. For pediatric members, PVRI > 3 Wood units × m2 is also acceptable
- For infants less than one year of age, PAH was confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
Reauthorization criteria
- Member is currently receiving a tadalafil product through a paid pharmacy or medical benefit and is experiencing benefit from therapy as evidenced by disease stability or disease improvement
Approval duration
12 months