Adempas — CareFirst (Caremark)
Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
Initial criteria
- Medication must be prescribed by or in consultation with a pulmonologist or cardiologist.
- For Pulmonary Arterial Hypertension (PAH):
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension.
- PAH was confirmed by right heart catheterization with all of the following pretreatment results:
- Mean pulmonary arterial pressure (mPAP) > 20 mmHg
- Pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg
- Pulmonary vascular resistance (PVR) > 2 Wood units.
- For Chronic Thromboembolic Pulmonary Hypertension (CTEPH):
- Member has CTEPH defined as WHO Group 4 class of pulmonary hypertension.
- Member has either recurrent or persistent CTEPH after pulmonary endarterectomy (PEA) OR inoperable CTEPH with diagnosis confirmed by BOTH of the following:
- Computed tomography (CT)/magnetic resonance imaging (MRI) angiography or pulmonary angiography.
- Pretreatment right heart catheterization with all of the following results:
- mPAP > 20 mmHg
- PCWP ≤ 15 mmHg
- PVR > 2 Wood units.
Reauthorization criteria
- Member has an indication listed in the coverage criteria.
- Member is currently receiving the requested medication through a paid pharmacy or medical benefit.
- Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement.
Approval duration
12 months