Yutrepia (treprostinil) — 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 WHO Group 1 class of pulmonary hypertension OR pulmonary hypertension associated with interstitial lung disease (PH-ILD; WHO Group 3)
Pulmonary hypertension confirmed by pretreatment right heart catheterization with all of the following: 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 × m2 is also acceptable)
For infants less than one year of age, pulmonary hypertension was confirmed by Doppler echocardiogram if right heart catheterization cannot be performed

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

12 months