Revatio — CareFirst (Caremark)

Pulmonary arterial hypertension (PAH) (World Health Organization Group 1)

Initial criteria

For PAH: Member has PAH defined as WHO Group 1 class of pulmonary hypertension
PAH confirmed by either pretreatment right heart catheterization showing mean pulmonary arterial pressure (mPAP) > 20 mmHg, pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg, and pulmonary vascular resistance (PVR) ≥ 3 Wood units in adults or pulmonary vascular resistance index (PVRI) ≥ 3 Wood units × m² in pediatric members; OR, for infants less than one year of age, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
Prescriber is or is in consultation with a pulmonologist or cardiologist for the diagnosis of PAH
For Secondary Raynaud’s phenomenon: Member has had an inadequate response to at least 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
Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement

12 months