Revatio — CareFirst (Caremark)
PAH (WHO Group I) in pediatric members less than 1 year of age
Initial criteria
- Medication must be prescribed by or in consultation with a pulmonologist or cardiologist for the diagnosis of pulmonary arterial hypertension (PAH)
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension
- PAH was confirmed by either:
- i. 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) ≥ 3 Wood units in adult members or pulmonary vascular resistance index (PVRI) ≥ 3 Wood units × m2 in pediatric members
- OR ii. For infants less than 1 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