ambrisentan — CareFirst (Caremark)
Pulmonary arterial hypertension (PAH) (WHO Group 1) in adults
Initial criteria
- Medication is prescribed by or in consultation with a pulmonologist or cardiologist
- Member has pulmonary arterial hypertension (PAH) defined as WHO Group 1 class of pulmonary hypertension
- PAH confirmed by either of the following:
- Pretreatment right heart catheterization showing all of the following: mean pulmonary arterial pressure (mPAP) > 20 mmHg, pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg, and pulmonary vascular resistance (PVR) > 2 Wood units (for pediatric members, pulmonary vascular resistance index (PVRI) > 3 Wood units x m² is also acceptable)
- For infants less than one year of age, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
Reauthorization 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