Opsynvi — CareFirst (Caremark)
Pulmonary arterial hypertension (PAH, WHO Group I, WHO Functional Class II–III)
Initial criteria
- Member has pulmonary arterial hypertension (PAH) defined as WHO Group 1 class of pulmonary hypertension
- PAH 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, and pulmonary vascular resistance (PVR) > 2 Wood units
- Medication prescribed by or in consultation with a pulmonologist or cardiologist
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