Orenitram (treprostinil extended-release tablets) — Cigna

Initial criteria

• Patient has a diagnosis of World Health Organization (WHO) Group 1 pulmonary arterial hypertension (PAH); AND
• Patient has had a right heart catheterization [documentation required]; AND results of the right heart catheterization confirm the diagnosis of WHO Group 1 PAH; AND
• Patient meets ONE of the following: (a) Patient has tried or is currently receiving at least one oral medication for PAH from the following different categories (either alone or in combination), each for ≥ 60 days: one phosphodiesterase type 5 (PDE5) inhibitor, one endothelin receptor antagonist (ERA), or Adempas (riociguat tablets); OR (b) Patient is receiving or has received in the past one PAH prostacyclin therapy or a prostacyclin receptor agonist (i.e., Uptravi [selexipag tablets]) for PAH; AND
• Medication is prescribed by or in consultation with a cardiologist or a pulmonologist.

Reauthorization criteria

• Patient has a diagnosis of World Health Organization (WHO) Group 1 pulmonary arterial hypertension (PAH); AND
• Patient has had a right heart catheterization; AND results confirm WHO Group 1 PAH; AND
• Medication is prescribed by or in consultation with a cardiologist or a pulmonologist.

Approval duration

1 year