Uptravi (selexipag) — CareFirst (Caremark)
Pulmonary arterial hypertension (PAH, WHO Group 1)
Initial criteria
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension.
- PAH was 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, 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 less than one year of age, PAH was confirmed by Doppler echocardiogram if right heart catheterization cannot be performed.
- Medication must be prescribed by or in consultation with a pulmonologist or cardiologist.
Reauthorization criteria
- Member is currently receiving Uptravi therapy 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