Adcirca — CareFirst (Caremark)

Secondary Raynaud’s phenomenon

Initial criteria

For PAH: Member has PAH defined as WHO Group 1 class of pulmonary hypertension
PAH confirmed by either of the following: Pretreatment right heart catheterization with all of the following results: mean pulmonary arterial pressure (mPAP) > 20 mmHg AND pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg AND pulmonary vascular resistance (PVR) > 2 Wood units (or PVRI > 3 Wood units x m2 for pediatric members)
For infants less than one year of age, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
Medication must be prescribed by or in consultation with a pulmonologist or cardiologist for the diagnosis of PAH
For Secondary Raynaud’s phenomenon: Member has had an inadequate response to at least one of the following medications: calcium channel blockers OR angiotensin II receptor blockers OR selective serotonin reuptake inhibitors OR alpha blockers OR angiotensin-converting enzyme inhibitors OR topical nitrates

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 improvement

12 months