Tyvaso — CareFirst (Caremark)
Pulmonary hypertension associated with interstitial lung disease (PH-ILD; WHO Group 3) to improve exercise ability
Initial criteria
- Prescribed by or in consultation with a pulmonologist or cardiologist
- Member has either of the following criteria: WHO Group 1 pulmonary hypertension OR pulmonary hypertension associated with interstitial lung disease (PH-ILD; WHO Group 3)
- Pulmonary hypertension confirmed by either of the following: 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) > 2 Wood units (for pediatric members, PVRI > 3 Wood units × m² acceptable) OR for infants < 1 year of age, PH 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 has an indication listed in the coverage criteria section
- Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement
Approval duration
12 months