Ventavis — CareFirst (Caremark)
Pulmonary arterial hypertension (PAH) (World Health Organization [WHO] Group 1)
Initial criteria
- Member has PAH defined as WHO Group 1 class of pulmonary hypertension
- PAH confirmed by 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 x m2 is also acceptable
- For infants age < 1 year, PAH confirmed by Doppler echocardiogram if right heart catheterization cannot be performed
- Medication prescribed by or in consultation with a pulmonologist or cardiologist
Reauthorization criteria
- 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
Approval duration
12 months