Tracleer — CareFirst (Caremark)
PAH in pediatric patients aged ≥ 3 years with idiopathic or congenital PAH to improve pulmonary vascular resistance
Initial criteria
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension
- PAH was confirmed by pretreatment right heart catheterization with ALL of the following results: 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 acceptable
- For infants age < 1 year, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
- Prescribed by or in consultation with a pulmonologist or cardiologist
Reauthorization criteria
- Member 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