Revatio — CareFirst (Caremark)

Pulmonary arterial hypertension (PAH) (WHO Group 1)

Initial criteria

Prescribed by or in consultation with a pulmonologist or cardiologist for the diagnosis of pulmonary arterial hypertension (PAH).
For pulmonary arterial hypertension (PAH) (WHO Group 1): Member has PAH defined as WHO Group 1 class of pulmonary hypertension.
PAH confirmed by either of the following: (a) Pretreatment right heart catheterization with 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 × m² is acceptable), OR (b) For infants less than 1 year of age, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed.
For secondary Raynaud’s phenomenon: Member has had an inadequate response to one of the following medications: calcium channel blockers, angiotensin II receptor blockers, selective serotonin reuptake inhibitors, alpha blockers, angiotensin-converting enzyme inhibitors, or topical nitrates.

Member is currently receiving the requested medication through a paid pharmacy or medical benefit and is experiencing benefit from therapy as evidenced by disease stability or disease improvement.

12 months