Letairis tablets — Cigna

Preferred products

• generic ambrisentan tablets
• Opsumit tablets
• generic bosentan tablets
• bosentan tablets for oral suspension
• Tracleer tablets for oral suspension

Initial criteria

• Patient meets the standard Pulmonary Arterial Hypertension − Endothelin Receptor Antagonist Prior Authorization Policy criteria; AND
• Patient has tried generic ambrisentan tablets; AND
• Patient cannot continue to use generic ambrisentan tablets due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the bioequivalent product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]

Approval duration

1 year